Case Report

Treatment Modalities for Early Management of Class III Skeletal

Malocclusion: A Case Series

Abstract Heena Sarangal,

The characteristic features of Class III malocclusion are present at an early age, usually between 3 and Ritu Namdev,
5 years of age. If left untreated, the Class III malocclusion or severe anterior crossbite may worsen, Swati Garg,
with the majority of these patients ultimately requiring orthognathic surgery as adults. The treatment
in all developing Class III cases should be undertaken as soon as the abnormality is diagnosed to Natasha Saini,
prevent it from becoming permanent and resulting in a full‑blown Class III malocclusion. It provides Parul Singhal
more pleasing facial esthetics (the lip posture and facial appearance), thus improving the psychosocial Department of Pediatric
development of a child. Various treatment options available for the management of developing Dentistry, Postgraduate Institute
Class III malocclusion are as follows: (1) functional appliances such as reverse twin block, Frankel of Dental Sciences, Rohtak,
Haryana, India
appliance, and the removable mandibular retractor; (2) orthopedic appliances such as chin cap and
face mask; and (3) orthodontic appliances, namely removable maxillary expansion plate or fixed
orthodontic appliance with expanded upper arch wire. A treatment plan may be chosen depending on
the amount of maxillary growth restriction, mandibular plane angle, the soft‑tissue profile, and the
age of the patient. This article discusses the various treatment options and the decision‑making for
different clinical cases based on the clinical features with a description of four different treatment
approaches.

Keywords: Anterior expansion appliance, Class III malocclusion, facemask, reverse twin block, two
by six appliances

Introduction features of skeletal Class III malocclusion.

Dentoalveolar component presents with
Due to increasing awareness regarding
retruded mandibular incisors and protruded
malocclusion and more concern about
maxillary incisors for dentoalveolar
esthetic in the general population in
compensation.[3]
present days, it is necessary for a dentist
to have immense knowledge and skills Class III malocclusion is of two types: (1)
about the diagnosis and treatment planning True Class III malocclusion and (2)
of the malocclusion to meet patient’s Pseudoclass III/functional Class III
Submitted : 10-Nov-2019
expectations. Nowadays, the patient reports malocclusion. PseudoClass III malocclusion Revised : 03-Jan-2020
to a clinician at very early age for the may be due to high points while occluding Accepted : 24-Feb-2020
correction of malocclusion. The prevalence teeth or functional shift. The diagnosis and Published : 13-Jul-2020

rate of Class III malocclusion varies treatment planning can be done considering
according to different racial categories. the following: (a) centric relation (CR), (b) Address for correspondence:
The mean incidence rate in Caucasians Dr. Heena Sarangal,
family history, (c) interincisal relationship, Room No. 9, Department
is 1%–4%,[1] with higher being found and (d) cephalometric findings.[4] True of Pediatric Dentistry,
in Asians (4%–14%).[2] The etiology of Class III malocclusion mostly has a positive Postgraduate Institute
Class III malocclusion is multifactorial. family history. Cephalometric findings may of Dental Sciences,
However, hereditary is the main etiological Rohtak, Haryana, India.
present with increased Sella–Nasion–B E‑mail: sarangalheena91@
factor. Other factors include environment, point (SNB) angle and small or decreased gmail.com
habits, and race. Class III malocclusion Sella–Nasion–A Point (SNA) angle,
is mainly due to skeletal component, retroclination of lower incisors, and less
dentoalveolar component, and combination incisor mandibular plane (MP) angle. Access this article online
of both. Prognathic mandible, retrognathic Cephalometric findings of pseudo/functional Website:
maxilla, or combinations of both are the www.contempclindent.org
Class III malocclusions show normal SNA,
DOI: 10.4103/ccd.ccd_393_19
slight increase in SNB angle, retroclined
Quick Response Code:
This is an open access journal, and articles are maxillary incisors, and normal lower
distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially,
as long as appropriate credit is given and the new creations are How to cite this article: Sarangal H, Namdev R,
licensed under the identical terms. Garg S, Saini N, Singhal P. Treatment modalities for
early management of class III skeletal malocclusion:
For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
A case series. Contemp Clin Dent 2020;11:91-6.

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 Sarangal, et al.: Treatment protocol for Class III malocclusion

incisors. Family history is usually absent. The functional cephalometric analysis revealed a deficient SNA angle and
shift can be seen.[5] increase in SNB angle. A decision to correct the anterior
interlock by bringing the maxilla forward with facemask
Case Reports therapy was made. An intraoral splint was fabricated
Case report 1: Anterior expansion appliance on the cast. The splint was cemented, and the facemask
was adjusted after 24 h of cementation. The patient was
A 9‑year‑old boy reported with permanent maxillary instructed to wear it for 14–16 h/day and change the elastics
incisors in reverse overjet relation with anterior deep bite daily. Adequate maxillary protraction was achieved within
of 4.1 mm. 11, 12, and 21 were lingually tipped, and 22 5½ months. Facemask was used for further 3 months for
was labially protruded. Functional shift and positive family retention. Pre‑operative and postoperative cephalometric
history were absent. Cephalometrically, child showed a values and images are shown in Table 1 (Case 2) and
skeletal Class III malocclusion which could be due to Figure 2, respectively.
dentoalveolar maxillary deficiency. Sagittal expansion with
posterior bite plane along with segmental fixed orthodontic Case report 3: Two‑by‑six fixed orthodontic appliance
treatment was planned. A maxillary appliance with a A 9‑year‑old boy reported with abnormal upper and lower
posterior bite plane was delivered, and segmental fixed teeth. On intraoral examination, permanent incisors and
orthodontics was done on four maxillary anteriors. Parents deciduous canines were in 1‑mm crossbite, and spaces
were instructed about the activation schedule of a quarter were present between both set of incisors. The profile was
turn every 3rd day and to report after 3rd week to change straight. SNA and SNB were in the normal range; however,
wire for fixed treatment. After the correction of crossbite SNB was on a slightly higher side. 2 × 4 segmental
in 3 months, further activation of expansion appliance orthodontics was undertaken in the lower arch to close the
was stopped. Fixed orthodontic treatment was continued spaces present between incisors and deciduous canines.
for space closure of anteriors, which was removed after Deciduous canines were also bonded considering the
correction. The patient was advised for regular follow‑up. space between lower lateral incisor and deciduous canine.
Cephalometric pre‑values and postvalues are shown in Upper expansion with a posterior bite plane was given
Table 1 (Case 1), and pre‑operative and postoperative for the correction of crossbite in the canine region. After
results are shown in Figure 1. the closure of spaces between incisors in 3 months time,
Case report 2: Face mask patient upper arch was also banded and bonded (2 × 4) along with
deciduous canines for the closure of space between upper
An 8‑year‑old boy presented with a chief complaint of incisor and canines. The upper arch space closure occurred
abnormal upper and lower anterior teeth. On extraoral in 2 months. The pre‑treatment and posttreatment results
examination, a concave profile was evident with mild are shown in Table 1; case 3 and images are shown in
eversion of the lower lip. Intraoral examination revealed Figure 3.
a mixed dentition period, with permanent maxillary
Case report 4: Reverse twin block
central incisors in reverse overjet relation revealing a
reverse overbite of 3 mm. No premature incisal contacts A child aged 6 years reported with inwardly placed
were observed, and functional shift was absent. There upper front teeth. There was no family history of Class
was a familial history of Class III malocclusion. The III malocclusion. The lower deciduous first molars were

a b c d

e f g
Figure 1: (a and b) Preoperative frontal and lateral extraoral profile. (c) Preoperative intraoral view. (d) Sagittal expansion appliance. (e and f) Postoperative
frontal and lateral extraoral profile view. (g) Postoperative intraoral view

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 Sarangal, et al.: Treatment protocol for Class III malocclusion

a b c
a b

f
d e

d e

f g h
Figure 3: (a‑c) Preoperative extraoral and intraoral photographs.
(d and e) Intraoral frontal views showing two‑by‑six fixed orthodontic
appliance. (f‑h) Postoperative extraoral and intraoral pictures
h i j
Figure 2: (a‑c) Preoperative extraoral and intraoral photographs.
(d and e) Extraoral view showing petite facemask. (f and g) Intraoral Table 1: Cephalometric Analysis
frontal and upper occlusal view showing intraoral cemented appliance.
(h‑j) Postoperative extraoral and intraoral pictures
Case 1 Case 2 Case 3 Case 4
Pre Post Pre Post Pre Post Pre Post
extracted by some private practitioner 5 months ago. On SNA (°) 79 82 78 82 82 82 78 82
SNB (°) 81 81 79.8 80.2 81 80 80 80
examination, anterior crossbite due to postural shift of
ANB (°) −2 1 −1.8 1.8 1 2 −2 2
the mandible in a Class III position was present. Lateral
Wit’s appraisal −8 −2 −3.9 −1 −6 −2 −5 −1.2
cephalometric revealed SNA in normal range and SNB
(mm)
slightly greater than normal values [Table 1 case 4].
FMA (°) 26 25.8 24 27.6 24.5 24.8 26.6 29
A diagnosis of pseudoClass III malocclusion was made.
IMPA (°) 84 81 80 81.9 86 88 95.3 97.2
Reverse twin‑block appliance was fabricated and activation
Angle of −3 0 −4 −1 −2 0 −3 −1
every 2–3 weeks by acrylic resin addition on inclines of convexity (mm)
blocks was done. The correction of anterior crossbite Y axis (°) 58.6 60.2 60 64 60 61 58.2 60
within 1 month of appliance wear and another 6 weeks was SN length (mm) 60.6 64 59 65 67 68 66.4 68.2
continued for retention. The pre‑operative and postoperative Inter‑incisal angle 126 127.2 128 126.8 129 130.6 130 131
results are shown in Figure 4. (°)

Discussion
appliances, for example, reverse twin block, Frankel
The purpose of early orthodontic treatment is to appliance, and removable mandibular retractor (RMR);
intercept the developing malocclusion and redirecting it
(b) orthopedic appliances, for example, facemask and chin
to physiological development. Interception of Class III
cup; and (c) orthodontic appliances, for example, removable
malocclusion can prevent irreversible soft‑ and hard‑tissue
maxillary expansion plate. The choice of appliance depends
changes, which includes labial plate thinning in anterior
region, gingival recession, interincisal compensation, labial on the age of the patient, soft‑tissue profile, and growth
wearing of mandibular incisors, overclosure of mandible, of maxilla. For the correction of retrognathic maxilla and
simplification of comprehensive treatment, and eliminate prognathic mandible, facemask and chin cup can be used,
the necessity of orthognathic surgery in some cases. respectively.[5]
Facemask or chin cup orthopedic therapies improve the The types of primary anterior teeth crossbites include
skeletal component, decrease dentoalveolar compensation, Type 1 – Pseudo/Functional Class III malocclusion and
improve occlusal harmony, and provide psychological Type 2 – True Class III malocclusion. Type 1 Class III
benefits to the patient by achieving esthetics.[3] malocclusion includes occlusal prematurities leading to
For the correction of developing Class III malocclusion, CR‑centric occlusion (CO) deviation. Type 2 Class III
appliances are categorized as follows: (a) functional malocclusion includes clinical features (retrognathic

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 Sarangal, et al.: Treatment protocol for Class III malocclusion

a b c
Figure 4: (a) Preoperative intraoral frontal view. (b) Reverse twin‑block appliance. (c) Postoperative intraoral frontal view

maxilla, prognathic mandible, and concave profile) with blocks results in satisfactory and long term, functional,
no CR‑CO deviation with supporting cephalometrics. and esthetic changes and can decrease the need of future
Family history is mostly positive. Type 1 is further orthognathic surgery.
classified into Type 1a and Type 1b. Type 1a is also
Anterior expansion appliance
known as simple malocclusion (presence of functional
shift with normally inclined anterior teeth). Type 1b In developing class III malocclusion in which maxillary and
is also called complex malocclusion, presents with mandibular skeletal bases are normal but anterior shift of
abnormal dentoalveolar relations that imitate true mandible results in dentoalveolar crossbite. In these cases
Class III malocclusion.[6] sagittal anterior expansion appliance is used to correct
anterior maxillary interlock. Observation for true Class III
The treatment modalities for Type 1a include simple
pattern till growth spurt at 18 years of age is needed.
disocclusion maxillary appliance such as posterior bite
Machado et al.[8] in a case report summarized that efforts
plane or reverse twin block. For Type 1b malocclusion,
should be made toward an early correction of a developing
sagittal expansion appliance with posterior bite plane is the
Class III malocclusion, especially when associated with
treatment of choice. Treatment option for Type 2 mainly
anterior crossbite.
depends upon the inter‑incisal relationship. If edge‑to‑edge
bite is present, RMR is the treatment of choice. In case of Chin cap
anterior deep bite, face mask can be used.[6] Chin cap indicated primarily in deciduous and early
The following two things are important for a case to be mixed dentition phase with low MP angle cases. It
treated with functional appliance: (1) mild retrognathic causes a downward and backward rotation of mandible
maxilla and (2) absence of very steep MP angle. For and controls mandibular growth at chin. Compliances
treatment planning, esthetic and soft‑tissue profile plays an needed. The results are unpredictable. The results
important role, as poor case selection may cause inadvertent depend on the account of force applied and the duration
results. Patient’s compliance and unpredictable mandibular of daily wear. A cephalometric study performed by
growth are the challenging factors for the pediatric dentist. Graber showed that the use of a chin cup promoted a
Facemask and expansion plates with posterior bite plane backward movement of Point B, due to a clockwise
lead to steeper MP angle, which will cause increase in rotation of the mandible. The length of the mandible also
vertical facial height.[5,6] decreased by about 1 mm due to the pressure transmitted
by the chin cup to the condyle, which generated, on
Various appliances have been reported in the literature for
the other hand, a delay in vertical growth.[9] In another
the correction of developing Class III malocclusion.[4]
study, Sakamoto et al. evaluated the skeletal changes
Detail of appliances produced before, during, and after chin cup therapy.
The authors concluded that chin cup therapy would
Facemask with or without expansion screw
be a very useful and efficient method for correcting
Cases that show skeletal maxillary retrognathism with low Class III malocclusion with mandibular prognathism.[10]
MP angle are the cases opt for treatment with facemask. In addition, Sugawara described that an early treatment
Family history is positive along with the absence of with a chin cup produced positive orthopedic effects
mandibular shift. The ideal age for facemask therapy is on the mandible.[11] Singh et al. reported a case report
6–8 years, and it can be started as soon as the patient can of developing Class III malocclusion, treated with chin
handle the appliance and have good compliance. Facemask cup therapy followed by fixed orthodontic treatment and
can be used with skeletal anchorage such as titanium Class III elastics. The author concluded that chin cup
screw/osseointegrated implants, and facemask acts by therapy is beneficial if it is started at the right time.[12]
promoting maxillary growth and restricting mandibular
Reverse twin block and Frankel appliance
growth. Problems associated with facemask therapy are
patient compliance, chances of relapse as a result of late Clark has described reverse twin block version of twin
mandibular growth. A case report by Bedolla et al.[7] block that may be used for Class III malocclusion. Inclined
related to the early treatment of skeletal Class III during planes angulations are reversed, and it works on harnessing
primary dentition stage concluded that facemask plus a of occlusal forces to facilitate maxillary advancement.
rapid maxillary expansion appliance with posterior bite A three‑way expansion screw is used for both sagittal and

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 Sarangal, et al.: Treatment protocol for Class III malocclusion

transverse expansion of the maxilla. Ideal cases with minimal the development of skeletal Class III malocclusion. By the
maxillary skeletal deficiency and edge‑to‑edge inter‑incisors correction of dental origin of problem, skeletal problem can
relation are the cases of choice for reverse twin block. The be minimized or reduced if diagnosed at an early stage.
maxillary advancement starts within 4–6 weeks, and average
treatment time is generally 6 months to establish a positive Conclusion
overjet. The addition of acrylic to inclined planes is needed The basic goal of early treatment of Class III skeletal
to increase to forces over the maxilla and mandible. Sargod malocclusion is to enable the child to close the mouth in
et al. reported a case of Class III malocclusion in primary CR by improving anterior teeth relation thus permitting
dentition and treated with reverse twin block concluded normal growth of maxilla and mandible and their normal
that reverse twin block can be used successfully for early relationship. The choice of the appliance should be based
treatment of Class III malocclusion in primary dentition.[13] on the age of the patient, soft‑tissue analysis, growth
Ulgen and Firatli studied the effect of Frankel functional of maxilla, inter‑incisal relationship, and cephalometric
regulator on 40 functional Class III malocclusion patients, findings.
with a mean age of 9.5 years and found a significant increase
in A point, Nasion and B point (ANB) angle as a result of Declaration of patient consent
decrease in SNB angle due to downward and backward The authors certify that they have obtained all appropriate
rotation of the mandible.[14] patient consent forms. In the form the patient(s) has/have
Removable mandibular retractor given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal. The
Maxillary resin plate with labial archwire extending to the patients understand that their names and initials will not
labial surfaces of mandibular incisors acts by providing be published and due efforts will be made to conceal their
proprioceptive stimuli to restrict the forward movement of identity, but anonymity cannot be guaranteed.
mandible. It can be used with expansion screw, with minimal
overbite and steep MP angle. A randomized controlled trail Financial support and sponsorship
done by Majanni and Hajeer with an objective to evaluate Nil.
skeletal, dental, and soft tissue changes following early
Conflicts of interest
Class III treatment and compared between removable
mandibular RMR group and bone anchored intermaxillary There are no conflicts of interest.
traction (BAIMT) group. Thirty‑eight participants with a
mean age of 11.46 were included. The author concluded References
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