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A to Z Orthodontics. Volume 16: Class III Malocclusion

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A to Z
ORTHODONTICS
Volume: 16

CLASS III
MALOCCLUSION
Dr. Mohammad Khursheed Alam
BDS, PGT, PhD (Japan)
 First Published August 2012

© Dr. Mohammad Khursheed Alam

© All rights reserved. No part of this publication may be reproduced stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without prior permission of author/s or publisher.

ISBN: 978-967-0486-05-5
Correspondance:

Dr. Mohammad Khursheed Alam

Senior Lecturer

Orthodontic Unit

School of Dental Science

Health Campus, Universiti Sains Malaysia.

Email:

dralam@gmail.com

dralam@kk.usm.my

Published by:
PPSP Publication
Jabatan Pendidikan Perubatan, Pusat Pengajian Sains Perubatan,

Universiti Sains Malaysia.

Kubang Kerian, 16150. Kota Bharu, Kelatan.

Published in Malaysia

1
 Contents

1. Class III Mo………….…..……................................3-4

2. Classification…………..………...............................5

3. Treatment………………………….…………………6-9

4. Crossbite………………………...............................10-15

2
Occlusal features of class III malocclusion

1. Incisor & Molar relationship: Class III incisor relationship & angle Class

III Molar relationship.

2. SK pattern: Usually Class III, but in pseudo Class III cases the SK

pattern may be class I or mild Class III.

3. Soft tissue Morphology & behavior:

Lips: In most cases lips are sealed at rest but the upper lip may be short &

lower everted & flabby. When both jaws are rather large, there is adequate

lip cover, but in patients with long face, there is frequently a deficiency in lip

length compared with face height with consequent incompetent lips.

Tongue: Tongue size tends to reflect the size of the lower jaw & many

Class III cases have large tongue. Tongue position is low & forward with

normal swallowing, but in cases with increased anterior inter-maxillary

height & anterior open bite, there may be an adaptive variation of

swallowing behavior with the tongue coming forward in the gap.

5. Upper incisors: Usually proclined, but in pseudo type (group III) they may

be retroclined.

6. Lower incisors: Usually retroclined, but in pseudo type they are

commonly proclined & spaced.

3
7. Overjet: Usually reversed. In mild SK III cases patient may often bite

edge to edge.

8. Overbite: Usually reversed overbite of variable degrees or even

openbite. Pseudo Class III cases may bite edge to edge.

9. Cross bite: Sometimes occur due to wide mandible or narrow maxilla.

This is often aggravated by forward position of mandible relative to the

maxilla in some cases.

10. Dental Arch: Maxillary arch tend to be shorter & narrower than the

mandiblar arch in some extreme cases (Mostly in group I)

11. Dento-alveolar disproportion: Disproportion is more common in the

upper arch.

12. F.M. plane Angle: High in group I, normal to low in group II & usually

normal in group III cases.

13. Mandibular posture & path of closure: Usually there is simple hinge

movement at the condyles from rest to occlusion. In a number of cases,

with mild Class III incisor relationship & normal or increased overbite,

forward & upward movement of mandible from ‘edge to edge’ may take

place often with over closure.

4
Maccallin classified the Class III malocclusion cases as:

 Group 1: Cases with skeletal III dental base, small maxilla,

excessive anterior facial height, long mandible and high F.M. plane

angle. Usually a degree of open bite and obtuse gonial angle.

 Group 2: Cases with skeletal III dental base, and mandibular

prognathism (large). Maxilla may be normal or large (but not small)

with normal to low F.M. plane angle. Overbite tends to be increased,

with a tendency of over closure.

 Group 3: `Pseudo' Class III cases with normal or very mild Class III

skeletal pattern. Patient can usually bite to an edge to edge relation

and the condition is the result of loss of deciduous molars at a critical

stage in development and an initial contact at incisors has fostered

slight forward movement and over closure, with the upper incisors

erupting lingual to the lowers.

5
Treatment of Class-III Malocclusion

Treatment aims

 To improve the aesthetics and the function of the teeth and jaws

while maintaining or improving the facial profile.

 To relieve crowding and align the teeth within the arches.

 To correct the incisor relationship to obtain a satisfactory overjet,

overbite and interincisal angle.

 To eliminate antero-posteriorly and unilateral lateral crossbite

together with associated displacements.

Main objective of Treatment:

Move the Upper incisors forward over the bite and increase the

antero-posterior dimension of the upper dental arch.

Aim of Tretment:

 Proclination of Upper Labial segment or Move the Upper Labial

segment forward (with or without extrusion)

 (Or) Retroclination of Lower Labial segment

 (or) Proclination of upper Labial segment as well as Retroclination of

Lower Labial segment (with or without extrusion)

The main objective of treatment is to move the upper incisors forward over

the bite and increase the antero-posterior dimension of the upper dental

6
arch.

Upper extraction should be avoided if possible and lower extraction is

undertaken unless there is spacing in lower arch.

Prognosis depends on: Type of overjet, degree of overbite and

skeletal prenormality. Soft-tissue factor have very little effect except large

tongue or tongue thrust.

1 CASES WITH POSITIVE BUT REDUCED OVERJET OR

FUNCTIONING EDGE TO EDGE INCISOR RELATIONSHIP:

In these cases, the incisor relationship is generally accepted and the

problem of crowding is dealt with by retracting upper buccal

segments just sufficient to align teeth.

Extraction of 4/4 is not indicated as it may create much space.

2 CASES WITH REVERSE OVERJET:

Where the upper incisors occlude lingually to the lower incisors, two

principle factors influence treatment. They are:

the degree of skeletal prenormality

and the amount of overbite

A Reverse overjet with increased overbite:

(i) Mild cases - procline upper incisor as soon as they erupt. If

crowding is present, upper buccal segment may be retracted to align the

7
teeth, or extraction of teeth as far back as possible can be done.

(ii) Moderate cases - (Moderate skeletal III pattern with excessive

overbite).

If no spacing in lower arch, extract 4/4 and retrocline lower labial

segment with minimum proclination of upper labial segment.

If there is spacing in the lower arch, it may be retroclined with

minimum proclination of upper labial segment.

(iii) Severe cases - (severe Class III skeletal pattern with extreme

overbite).

Prognosis is poor.

Procline upper and retrocline lower with or without extraction of 4/4

depending on lower arch dento-alveolar position.

Or, surgical treatment by mandibular resection.

B Reverse overjet but normal or reduced overbite:

(i) In normal or mild skeletal cases with reduced overbite, upper labial

segment may be proclined and extruded.

(ii) In moderate skeletal cases with reduced overbite, 4/4 may be

extracted. Retrocline lower labial segment & proclin upper labial segment

with or without their extrusion.

(iii) In severe skeletal cases, with frank openbite, orthodontic

8
treatment is not likely to be successful. Mandibular resection should be the

answer.

In some cases, it is better to treat crowding in the upper and if

necessary in the lower arch, so as to provide the patient with well aligned

dental arches, but still with a severe overjet in the incisor region.

9
CROSS BITE

Definition: Graber has defined cross bit as a condition where one or more

teeth may be abnormally malposed bucally or lingually or labially with

reference to the opposing tooth or teeth.

Plane: Abnormal occlusion in the transverse plane.

Synonym: Reverse jet of one or more teeth.

Classification:

(a) Based on their location –

1. Anterior cross bite. (a) Single tooth.

2. Posterior cross bite. (b) Segmental

a) Unilateral

b) Bilateral

(b) Based on nature of cross bite –

1) Skeletal cross bite.

2) Dental cross bite.

3) Functional cross bite.

Anterior cross bite:

This is a condition where a reverse jet is seen. The mandibular anterior

teeth overlap the maxillary anteriors. An anterior cross bite involves a

single tooth or an entire segment of the arch.

10
Posterior cross bite

This refers to an abnormal transverse relationship between the upper and

lower posterior teeth. In this condition, instead of the mandibular buccal

cusp occluding in the central fossa of the maxillary posterior teeth they

occlude buccal to the maxillary buccal cusp. Thus posterior cross bite

occurs as a result of lack of co-ordination in the lateral dimension between

the upper and the lower arches.

Buccal non occlusion

This is a form of posterior cross bite where the maxillary posteriors occlude

entriely on the buccal aspect of the mandibular posteriors. This condition is

also called as reverse cross bite or scissors bite.

Lingual non-occlusion:

This is a form of posterior cross bite where the maxillary posteriors occlude

entirely on the lingual aspect of the mandibular posteriors.

Etiology:

Anterior cross bite –

(1) Trauma.

(2) Arch length discrepancy.

(3) Retained deciduous teeth.

11
 (4) Failure of resorption of roots of deciduous leads to lingual eruption of

permanent teeth.

(5) Occlusal prematurities lead to forward path of closure causing

anterior cross bite.

(6) Loss of upper deciduous molars leads to collapse of maxillary

anterior arch leads to functional displacement.

(7) Asymmetric growth of maxilla and mandible.

Posterior cross bite:

1) Arch length discrepancy.

2) Retained deciduous tooth.

3) Due to thumb sucking.

4) Due to nasal obstruction.

5) Narrow maxilla.

6) Mouth breathing.

TREATMENT:

Diagnosis:

(1) History.

(2) Clinical examination.

(3) Study models.

(4) Radiographs – Intraoral periapical radiograph

12
 - Lateral cephalogram.

Anterior cross bite –

A) A developing cross bite can be managed by –

a) Tongue blade therapy.

b) Lower inclined plane therapy.

c) Placing a metallic crown on upper incisor tooth.

B) Already developed cross bite can be treated by any one of the following

ways –

a) Double cantilever spring with posterior bite plane.

b) Telescopic expansion screws i posterior bite plane.

c) Segmental expansion screw o posterior bite plane.

d) Multilsoped arch wires with fixed appliances to correct the single

tooth in cross bite.

Posterior cross bite:

A) For single tooth – corrected by

a) Cross elastics.

b) Sectional fixed appliance.

c) Expansions crews.

) Unilateral cross bite Corrected by

a) Using unilateral expansion screws.

13
 b) Using fixed appliance.

C) Bilateral cross bite – corrected by using

a) Symmetrical expansion screws.

b) Coffin spring.

c) Quad helix appliance.

d) Hyrax.

Bilateral cross bite:

Expansion or contraction of arch

This condition usually accepted, left untreated.

Unilateral cross bite

• Lateral expansion of narrow arch.

• Expansion by F.A or R. A e post bite plane.

• Unilade. CB e no Mn displacement – left untreated.

* Cleft palate case – Mx arch expanded to correct collapse of the arch &

retained by permanent retainer on bone grafting.

Reverse CB

Contraction of upper arch &

Expansion of lower arch

Prognosis Poor

14
Reverse cross bite:

Synonym – Scissors Bite

It is produced when due to transverse malrelationship of dental arches the

maxillary buccal teeth occlude completely buccal or lingual to the

mandibular teeth.

• It occurs due to wider & narrower maxillary dental arch.

• This usually unilateral, but may also be bilateral.

• Due to lack of occlusion of these teeth, they tend to continue to erupt

causing traumatic occlusion.

Treatment

• When due to wider upper arch –

- Contraction of upper arch & expansion of lower arch.

• When due to narrower upper arch –

- Expansion of upper arch & contraction of lower arch.

15
Bibilography:
1. Bhalajhi SI. Orthodontics – The art and science. 4th edition. 2009

2. Gurkeerat Singh. Textbook of orthodontics. 2nd edition. Jaypee, 2007

3. Houston S and Tulley, Textbook of Orthodontics. 2nd Edition. Wright, 1992.

4. Iida J. Lecture/class notes. Professor and chairman, Dept. of Orthodontics, School of dental
science, Hokkaido University, Japan.

5. Lamiya C. Lecture/class notes. Ex Associate Professor and chairman, Dept. of Orthodontics,

Sapporo Dental College.

6. Laura M. An introduction to Orthodontics. 2nd edition. Oxford University Press, 2001

7. McNamara JA, Brudon, WI. Orthodontics and Dentofacial Orthopedics. 1st edition, Needham
Press, Ann Arbor, MI, USA, 2001

8. Mitchel. L. An Introduction to Orthodontics. 3 editions. Oxford University Press. 2007

9. Mohammad EH. Essentials of Orthodontics for dental students. 3rd edition, 2002

10. Proffit WR, Fields HW, Sarver DM. Contemporary Orthodontics. 4th edition, Mosby Inc., St.Louis,
MO, USA, 2007

11. Sarver DM, Proffit WR. In TM Graber et al., eds., Orthodontics: Current Principles and
Techniques, 4th ed., St. Louis: Elsevier Mosby, 2005

12. Samir E. Bishara. Textbook of Orthodontics. Saunders 978-0721682891, 2002

13. T. M. Graber, R.L. Vanarsdall, Orthodontics, Current Principles and Techniques, "Diagnosis and
Treatment Planning in Orthodontics", D. M. Sarver, W.R. Proffit, J. L. Ackerman, Mosby, 2000

14. Thomas M. Graber, Katherine W. L. Vig, Robert L. Vanarsdall Jr. Orthodontics: Current Principles
and Techniques. Mosby 9780323026215, 2005

15. William R. Proffit, Raymond P. White, David M. Sarver. Contemporary treatment of dentofacial
deformity. Mosby 978-0323016971, 2002

16. William R. Proffit, Henry W. Fields, and David M. Sarver. Contemporary Orthodontics. Mosby
978-0323040464, 2006

17. Yoshiaki S. Lecture/class notes. Associate Professor and chairman, Dept. of Orthodontics, School
of dental science, Hokkaido University, Japan.

18. Zakir H. Lecture/class notes. Professor and chairman, Dept. of Orthodontics, Dhaka Dental
College and hospital.

16
 Dedicated To

My Mom, Zubaida Shaheen

My Dad, Md. Islam
&
My Only Son
Mohammad Sharjil

17
 Acknowledgments
I wish to acknowledge the expertise and efforts of the various
teachers for their help and inspiration:

1. Prof. Iida Junichiro – Chairman, Dept. of Orthodontics,

Hokkaido University, Japan.
2. Asso. Prof. Sato yoshiaki –Dept. of Orthodontics, Hokkaido
University, Japan.
3. Asst. Prof. Kajii Takashi – Dept. of Orthodontics, Hokkaido
University, Japan.
4. Asst. Prof. Yamamoto – Dept. of Orthodontics, Hokkaido
University, Japan.
5. Asst. Prof. Kaneko – Dept. of Orthodontics, Hokkaido
University, Japan.
6. Asst. Prof. Kusakabe– Dept. of Orthodontics, Hokkaido
University, Japan.
7. Asst. Prof. Yamagata– Dept. of Orthodontics, Hokkaido
University, Japan.
8. Prof. Amirul Islam – Principal, Bangladesh Dental college
9. Prof. Emadul Haq – Principal City Dental college
10. Prof. Zakir Hossain – Chairman, Dept. of Orthodontics,
Dhaka Dental College.
11. Asso. Prof. Lamiya Chowdhury – Chairman, Dept. of
Orthodontics, Sapporo Dental College, Dhaka.
12. Late. Asso. Prof. Begum Rokeya – Dhaka Dental College.
13. Asso. Prof. MA Sikder– Chairman, Dept. of Orthodontics,
University Dental College, Dhaka.
14. Asso. Prof. Md. Saifuddin Chinu – Chairman, Dept. of
Orthodontics, Pioneer Dental College, Dhaka.

18
 Dr. Mohammad Khursheed Alam
has obtained his PhD degree in Orthodontics from Japan in 2008.
He worked as Asst. Professor and Head, Orthodontics
department, Bangladesh Dental College for 3 years. At the same
time he worked as consultant Orthodontist in the Dental office
named ‘‘Sapporo Dental square’’. Since then he has worked in
several international projects in the field of Orthodontics. He is
the author of more than 50 articles published in reputed journals.
He is now working as Senior lecturer in Orthodontic unit, School
of Dental Science, Universiti Sains Malaysia.

Volume of this Book has been reviewed by:

Dr. Kathiravan Purmal
BDS (Malaya), DGDP (UK), MFDSRCS (London), MOrth
(Malaya), MOrth RCS( Edin), FRACPS.
School of Dental Science, Universiti Sains Malaysia.

Dr Kathiravan Purmal graduated from University Malaya 1993.

He has been in private practice for almost 20 years.
He is the first locally trained orthodontist in Malaysia with
international qualification. He has undergone extensive
training in the field of oral and maxillofacial surgery and
general dentistry.

19

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