ORTHODONTIC CAMOUFLAGE TREATMENT OF DENTOSKELETAL CLASS III MALOCCLUSION WITH PREMOLAR EXTRACTION (Case Report)

(1)

Orthodontic Camouflage Treatment Of Dentoskeletal

Class III Malocclusion With Premolar Extraction

Dr. drg. Tita Ratya Utari, Sp. Ort

(Case Report)

Lecturer, Department of Orthodontics, School of Dentistry

Faculty of Medicine and Health Science Universitas Muhammadiyah

Yogyakarta

(2)

Introduction

• _{Class III malocclusions represent a small}

proportion of all malocclussions among orthodontic patients but the treatment is considerable clinical challenge

because of the complex diagnosis and the difficult prognosis (Antonio, 2012).

The Class III malocclusion has a strong

genetic background which may express itself

(3)

Class III malocclusion is far more prevalent in Asian countries than in the West. (Graber Mosby, 2005 in A-Bakr M. Rabie, 2008)

Southeast Asian populations have the

highest prevalence of Class III malocclusion (13% to 27%), while Indian and Caucasian

(4)

 _{Narrow ”cranial angle”,}

 _{Anteroposterior shortening of}

maxilla,

 _{Hyperdivergent skeletal pattern}

(openbite),

 _{Posterior discrepancy,}

 _{Flaring out of upper anterior teeth,}  _{Incline to lingual in lower incisors,}  _{Prognatic mandible, and}

 _{Flat occlusal plane.}

The general characteristics of

skeletal class III:

(5)

Treatment Alternatives For Skeletal

Class III Malocclusion

There are three main

treatment options for skeletal class III malocclusion:

Growth Modification,

Dentoalveolar

Compensation (Orthodontic Camouflage),

Orthognatic Surgery. A-Bakr M. Rabie, et al. 2008. Treatment in

Borderline Class III Malocclusion: Orthodontic Camouflage (Extraction) Versus Orthognathic

Surgery

Growth modification should be commenced before the

pubertal growth spurt, after this spurt, only the latter two options are possible.

Growth modification should be commenced before the

(6)

• _{There are larger number of skeletal class}

III patient that either decline or cannot afford surgical treatment.

• _{The only alternative is “orthodontic}

camouflage” through comprehensive treatment with fixed appliances.

• _{There are type of Orthodontic camouflage:}

1.Selective tooth extraction.

2.Distalization of mandibular dentition using miniimplants.

Treatment Alternatives For Skeletal

Class III Malocclusion

(7)

Camouflage in Orthodontic

• _{Camouflage treatment is defined by Proffit}

as displacement of the teeth relative to

their supporting bone to compensate for an underlying jaw discrepancy.

• _{Thus, camouflage in orthodontics is defined}

as implementation of a less intensive

treatment plan option in a patient with a severe problem so as to obtain optimum results within physiologic limits and which may not be addressing the correction of the

(8)

•

Orthodontic camouflage

treatment can be performed in

Class III malocclusion patients

with the mild skeletal

discrepancy in patients with no

growth potential.

•

Selective tooth extraction

(premolars, lower incisors, or

lower second molars) is done

to correct only the dental

(9)

Objectives

•

To describe management

of dentoskeletal class III

malocclusion by

extraction of the upper

and lower right

(10)

Case Report

A patient:

19 years old

Javanese

Female

Pretreatment facial

photographs

(11)

Pretreatment Intraoral photographs

Class III Angle dentoskeletal malocclusion

(12)

Radiographic Examination

∠ SNA 84° ∠Facial (facial angle)

94°

∠ SNB 86° ∠Conv ( Angle of convexity)

-5°

∠ ANB -2° Bidang A-B +2°

I ke NA 6 mm FMPA 34°

∠ I ke NA 20° Sumbu Y ( Y axis) 60°

I ke NB 5 mm Oklusal Plane 15°

(13)

Vertikal Loop usage for protraction up anterior teeth.

Treatment

(14)

(15)

A common strategy of orthodontic camouflage treatment is the use of intermaxillary Class III elastics. Result in mesial movement of the upper dentition and distal

movement of the lower

(16)

Anterior crossbite was

corrected / edge to edge

(17)

Overjet and Overbite

were formed.

(18)

Space anterior has closed, right canine

still in class III, midline shift, patients are not satisfied with her

(19)

Radiographic

Examination

∠ SNA 840 ∠Facial (facial angle) 960

∠ SNB 860 _∠_{Conv ( Angle of}

convexity)

-30

∠ ANB -20 _{Bidang A-B} ₊₂0

I ke NA 9mm FMPA 340

∠ I ke NA 300 _{Sumbu Y (}_{Y axis)} ₅₈0

I ke NB 7 mm Oklusal Plane 80

(20)

The Next

Treatment

followed

by:

extraction of 15

• _{to improve}

right molar relations

extraction 44

• _{to correct}

the median line shift.

For late adolescent or adult patients with a moderate Class III malocclusion who refuse orthognathic surgery,

(21)

At the end of the treatment:

 _{anterior crossbite was corrected,}

 _{class I canine and molar relation with normal}

overbite overjet and median line was in a line, better profile

Result

Post-treatment

(22)

Post-treatment intraoral photographs

(23)

Radiographic

Examination

∠ SNA 820 _∠_{Facial (facial}

angle)

940

∠ SNB 840 _∠_{Conv ( Angle of}

convexity)

-20

∠ ANB -20 _{Bidang A-B} ₊₂0

I ke NA 8 mm FMPA 350

∠ I ke NA 27 Sumbu Y ( Y axis) 590

I ke NB 4 mm Oklusal Plane 100

(24)

(25)

(26)

(27)

Discussion

•

Orthodontic camouflage is well fit for

patients that carry small skeletal

Class III, with no growth potential,

with a relative fine facial balance and

without severe crowding.

•

This case was treated with straight

wire system appliance with vertical

U-loop to correct anterior crossbite

(28)

•

The several loop designs that have

been described have specific

applications and when properly

employed produce effective

responses.

• _{One of common applications of the loops in}

orthodontic treatment procedures is double vertical loop against bracket fixed to the

contained section of the arch wire activated by tying back or compression for mesial or distal movement (such as midline

correction).

(29)

Indication for class III

camouflage treatment

Indication for class III

camouflage treatment

• _{Too old for successful growth modification,}

• _{Mild to moderate skeletal class III,}

• _{Reasonably good alignment of teeth  so}

that the extraction space would be

available for controlled anteroposterior displacement and not used to relieve crowding,

• _{Good vertical facial proportions, neither}

extreme short face nor long face.

(30)

Class III Elastic

• _{Another form of camouflage is the use of}

Class III elastics, thus allowing a

compensation by lingualization of the lower incisors and labialization of the upper

incisors (Rey Mora, et al, 2007)

• _{Extended from upper molar to the lower}

cuspid.

• _{Bring about retrusion of mandibular}

anteriors and protusion of maxillary anteriors.

• _{Class III intermaxillary elastics were used to}

protract maxillary first molar from class III into class I relation (Bayirli B, 2009 in

(31)

•

Class III elastics also contribute to

correction of the overbite and overjet,

which was at the cost of retrusion of

the mandibular incisors and permitted

by extraction of lower premolar.

•

One of extraction pattern for class III

(32)

Extraction of

15

• _{Extraction of the maxillary second premolar in}

this case, could make the maxillary molars moved mesially into class I molar

relationship.

• _{Extraction of second premolar was first}

introduced by Nance in 1949.

• _{Nance suggested that borderline extraction}

cases with minimal crowding and cases to avoid over- retraction of the anterior

segments should be treated in conjunction with extraction of second premolars.

(33)

•

Schoppe and Schwab observed

that more mesial movement of

the posterior segments were

present in second premolar

extractions cases than in first

premolar extraction.

•

In some class III cases with

crowding, treatment may be

easier to consider extraction of

upper second and lower first

(34)

Extraction of 44

• _{Extraction of first premolar}

mandibular is to provide to move mandibular canines distally from a class III

relationship into a class I relationship and also to

correct the midline shifting.

• _{Premolar extraction also}

favored reducing the

mandibular prognathism by reducing the concavity,

(35)

• _{To improve the anterior cross bite or}

edge-to-edge bite, premolar extraction plays important role by providing space to

retract lower incisors. Usually patient with class III malocclusion having the concave

profile and after extraction of lower

premolar it may disturb the concave profile due to lingual inclination of lower incisors

compare to non extraction case (Alam MK

et al, 2016).

• _{To improve the anterior cross bite or}

edge-to-edge bite, premolar extraction plays important role by providing space to

retract lower incisors. Usually patient with class III malocclusion having the concave

profile and after extraction of lower

premolar it may disturb the concave profile due to lingual inclination of lower incisors

compare to non extraction case (Alam MK

(36)

Conclusion:

•

Camouflage treatment with

proper extraction can be

considered in a non-surgical

treatment of adult and give a

satisfactory result

•

All treatment goals have been

(37)

References

1. Paulo Beltrão. 2015. Class III High Angle Malocclusion Treated with Orthodontic Camouflage (MEAW Therapy). Issues in Contemporary Orthodontics Chapter 11. Licensee InTech. Download from http://www.intechopen.com/books

2. Snigdha Pattanaik, Noorjahan Mohammad, Sasmita Parida, Subhrajeet Narayan Sahoo. 2016. Treatment Modalities for Skeletal Class III Malocclusion: Early to Late Treatment. IJSS Vol 2 | Issue 8. Download from http://www.ijsscr.com/

3. Tekale PD, Vakil KK, Vakil JK, Parhd SM. 2014. Orthodontic Camouflage in Skeletal Class III Malocclusion: A Contemporary Review. J Orofac Res;4(2):98-102. Download from

www.jaypeejournals.com/eJournals

4. A-Bakr M. Rabie, Ricky W.K. Wong and G.U. Min. 2008. Treatment in Borderline Class III Malocclusion: Orthodontic Camouflage (Extraction) Versus Orthognathic Surgery. The Open Dentistry Journal, 2, 38-48

5. Sobral MC, Habib FAL, Nascimento AC de S. Vertical control in the Class III compensatory treatment. Dental Press Journal of Orthodontics. 2013 Apr;18(2):141–59.

6. Elastics in orthodontics /certified fixed orthodontic courses by Indi… [Internet]. 05:29:50 UTC [cited 2016 Aug 10]. Available from: http://www.slideshare.net/indiandentalacademy/elastics-in-orthodontics

7. Bhandari P, Anbuselvan G. Nonsurgical management of class III malocclusion: A case report. Journal of Indian Academy of Dental Specialist Researchers. 2014;1(1):35.

8. Suresh R. Class III Subdivision Malocclusion With Unilateral Posterior Crossbite. Kathmandu Univ Med J 2014;47(3): 207-10.

9. Phulari BS. Orthodontics: Principles and Practice. JP Medical Ltd; 2011. 674 p. in https://books.google.co.id