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Orthodontic decompensation and correction ofskeletal Class III malocclusion with gradual

dentoalveolar remodeling in a growing patient

Bin Cai,a Xiao-Guang Zhao,b and Lu-Sai Xiangc

Guangzhou, Guangdong, China

An 8-year-old girl with a skeletal Class III malocclusion was treated in 2 phases. Maxillary expansion and

protraction were carried out as the early intervention. However, her maxillary hypoplasia and mandibular hyper-

plasia deteriorated with age. The phase 2 comprehensive treatment began with proper mechanics when she was

12 years old with growth potential. In the maxillary arch, an auxiliary rectangular wire was used with a roundmain

wire and an opening spring to create space for the impacted teeth and to bodily move the anterior teeth forward.

Decompensation of mandibular incisors and correction of the Class III malocclusion were achieved by shortClass III elastics with light forces and a gentle interaction between the rectangular wires and the lingual root-

torque slots. The phase 2 active treatment period was 4 years 8 months. The 2-year follow-up indicated that

our treatment results were quite stable. (Am J Orthod Dentofacial Orthop 2014;145:367-80)

In the treatment of skeletal Class III malocclusion,there is no clear borderline between what can be

achieved by orthodontic camouage and what inev-itably requires orthognathic surgery. Comparatively,orthognathic surgery could obtain substantial skeletalimprovement as well as favorable tooth inclinations by

the presurgical decompensation. However, camouagetreatment demands more time and high patient compli-ance, although the treatment expenses and risks are

lower.1For patients who do not want the risk of surgery,early orthodontic intervention in the mixed dentitionfollowed by comprehensive treatment in the earlypermanent dentition is a valid therapy.2,3

Traditional orthodontic camouage of skeletal ClassIII malocclusion always results in more lingual inclina-

tion of the mandibular incisors and more proclinationof the maxillary incisors for compensation of a skeletaldiscrepancy.4 However, excessive inclination of the

incisors will not only ruin the dental esthetics but also

harm the surrounding periodontal tissues, probablyfrom the traumatic occlusal forces.5,6 Authors of a

previous study attempted to improve the compensativeinclination of themandibular incisors with mandibularskeletal anchorage.7

The patient's pubertal growth is the optimal timing

for routine orthodontic treatment because modicationsof dentoalveolar bone are easier in this stage. In general,

bone around the alveolar socket will remodel to the some

extent after orthodontic tooth movement.8,9 Iforthodontists could take the advantage of this periodto achieve orthodontic decompensation and tocorrect a Class III malocclusion at the same time bygradual alveolar remodeling with comprehensiveorthodontic treatment, further inclination of the

incisors and unfavorable side effects could be avoided.How much could the dentoalveolar remodelingcompensate for the base bone discrepancy? To answer

this question, we present a skeletal Class III patienttreated with early intervention and orthodonticcamouage. In her comprehensive orthodontic

treatment, we attempted to decompensate the incisorinclination during her growing stage with dentoaveolarremodeling.

DIAGNOSIS AND ETIOLOGY

An 8-year-old girl came for orthodontic consultationwith chief complaints of an anterior crossbite and adished-in face. Her parents said that her psychology

was negatively affected by her unesthetic facial

From the Department of Orthodontics, Hospital of Stomatology, Sun Yat-sen

University, Guangzhou, Guangdong, China.aAssociate professor.bLecturer.cPostgraduate student.

All authors have completed and submitted the ICMJE Form for Disclosure of

Potential Conicts of Interest, and none were reported.

Address correspondence to: Xiao-Guang Zhao, Department of Orthodontics,

Hospital of Stomatology, Sun Yat-sen University, 56 LingyuanWest Rd, Guangz-

hou, Guangdong, China 510055; e-mail,[email protected].

Submitted, revised and accepted, April 2013.

0889-5406/$36.00

Copyright 2014 by the American Association of Orthodontists.

http://dx.doi.org/10.1016/j.ajodo.2013.04.026

367

CASE REPORT
http://-/?-http://-/?-http://-/?-mailto:[email protected]:[email protected]://dx.doi.org/10.1016/j.ajodo.2013.04.026http://dx.doi.org/10.1016/j.ajodo.2013.04.026mailto:[email protected]://-/?-http://-/?-http://-/?-

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appearance. Her medical history showed no systemic dis-

eases or developmental anomalies. Her parents did nothave Class III characteristics.

The patient had a retrognathic maxilla and a

prognathic mandible with a sharp nasolabial angleand a concave facial prole (Fig 1). As shown by thecephalometric analysis, the ANB angle was 3.5,

and the Wits appraisal was 6.5 mm (Fig 2, Table).The intraoral examination indicated a Class III maloc-clusion with an anterior crossbite and a unilateralcrossbite. Cephalometrically, she had lingually inclinedmandibular deciduous incisors (Md 1 to MP, 66.8)and an excessive interincisal angle (166.1), which

was the dental compensation of the skeletal Class III

discrepancy. Her cephalogram showed that the lowerborder of the second through the fourth cervicalvertebrae had no concavity, indicating that she wasat cervical vertebral stage 1.10

Considering the severity of her skeletal problem, weexplained the possibility of orthognathic surgery to thepatient and her parents. However, they were reluctantto undertake the risks of surgery.

TREATMENT OBJECTIVES

The proposed treatment included 2 phases: earlyorthopedic intervention and comprehensive treatment.

Skeletally, we proposed to promote sagittal growth ofthe maxilla before her pubertal growth spurt to improvethe midfacial deciency and to eliminate the acute naso-labial angle; this could be done in therst stage. Mean-

while, the transverse coordination of the maxilla and themandible could be carried out by maxillary disjunction

with a palatal expander.Since it is impossible to limit the absolute growth

of mandible, changing the growth direction could behelpful in the improvement of her skeletal discrep-ancy. However, we did not expect to increase her

facial height much because it would ruin her facialbalance.

If her mandibular growth exceeded the maxillarygrowth too much, orthognathic surgery could not be

avoided. We explained this to the patient and her parentsbefore the treatment started.

Because the patient was reluctant to have surgery,dental camouage became the solution to compensatefor the skeletal discrepancy. The goals consisted ofachieving good dental alignment and establishing pos-terior interdigitation with Class I molar and canine rela-tionships. In addition, to obtain better facial esthetics

and more stability, we attempted to decompensate theinclination of the maxillary and mandibular incisors bydentoaveolar remodeling in her phase 2 treatment.

TREATMENT ALTERNATIVES

Since the patient and her parents cared about her

facial appearance, an early intervention of the skeletaldiscrepancy would benet her psychological health

and make the following treatment easier as well.2,3

Therefore, a plan of 2-phase treatment was made for her.In phase 1 of the treatment, facemask protraction and

chincap were 2 alternatives to improve the patient's facialappearance. Because she had a posterior crossbite, maxil-

lary retrognathism, and mandibular prognathism, themaxillary expander with facemask protraction was adop-ted. In the pretreatment cephalogram, her cervical verte-

bral maturation was judged to be at least 2 years beforethe pubertal growth spurt(stage 1); this was good timingfor facemask protraction.10 There are different types of

expanders including hyrax, Haas, and bonded expanders.

Because the maxillary

rst molars had not erupted yet, abonded expander was the choice for better retention.Phase 2 treatment would depend on mandibular

growth and the patient's preference. Orthognathicsurgery is a viable, and even optimal, option especially

for a severe skeletal discrepancy.11 It could correct notonly the dental problems but also the skeletal and softtissue discrepancies. However, the patient and herparents rejected it for its invasiveness and potentialcomplications. They were more willing to accept a

less-than-ideal result. Therefore, nonsurgical orthodon-tic treatment was considered. The timing to start thecomprehensive orthodontic treatment with dentalcamouage could be during the adolescent or thepostadolescent phase.

In the planning of nonsurgical orthodontic camou-age, a nonextraction strategy was preferred becauseextractions in the maxillary arch would increase theseverity of the anterior crossbite, whereas extractionsin the mandibular arch would cause further lingualinclination of the mandibular incisors.

TREATMENT PROGRESS

The phase 1 treatment was started with a bondedmaxillary expander and facemask protraction (Fig 3).

The patient was asked to activate the screw twice daily(0.25 mm per turn). After 2 weeks, the screw wassuccessfully opened by 7 mm, and the posterior crossbite

was corrected. Then it was xed to hold the expandedspace in the maxilla. Facemask protraction was usedabout 12 to 14 hours per day with a force of 500 cNper side. The protractor was worn for 1 year 2 monthsuntil the positive overjet was stable (Fig 4). The cephalo-

metric analysis (Fig 5,Table) showed that the SNB angledecreased from 78.5 to 76.0, whereas the mandibularplane angle increased from 26.3 to 29.3. Therefore, the

368 Cai, Zhao, and Xiang

March 2014 Vol 145 Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics

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Fig 2. Pretreatment cephalometric and panoramic radiographs.

Fig 1. Pretreatment facial and intraoral photographs.

Cai, Zhao, and Xiang 369

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Fig 3. Bonded expander was used with facemask protraction.

Fig 4. Intraoral photographs after phase 1 treatment.

Fig 5. Cephalometric and panoramic radiographs after phase 1 treatment.



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Fig 6. Facial and intraoral photographs before phase 2 treatment.

Fig 7. Dental casts before phase 2 treatment.



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At the 2-year follow-up, the patient's stable occlu-sion was maintained along with satisfactory dentaland smile esthetics (Figs 15 and 16). Cephalometri-cally, the inclination of the mandibular incisors

slightly relapsed (Md 1-MP, from 83.0 to 81.9),but this was still much better than before the phase2 treatment (61.2) (Fig 17). The superimpositions ofthe posttreatment and the 2-year follow-up tracingsindicated that the patient had a little vertical growth,

and her skeletal structure and dental inclination werestable (Fig 18).

DISCUSSION

The patient clearly had a skeletal Class III discrepancywhen she was 8 years old at her rst visit. The lingual incli-nation of the mandibular deciduous incisors (66.8)reminded us of the severity of her skeletal malocclusion.Therefore, the challenges in her treatment included

Fig 8. Cephalometric and panoramic radiographs before phase 2 treatment.

Fig 9. Intraoral progress photographs. The treatment started from the maxillary arch, and a 0.017 3

0.025-in stainless steel wire was used as an auxiliary wire in the distalization of the maxillary rstmolars.



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improving her skeletal relationship and eliminating thecompensation of mandibular incisors' lingual inclinationas much as possible.

Her 2-phase treatment consisted of early orthopedicintervention and comprehensive orthodontic treatment.

Many investigators have proclaimed the importance of

earlyintervention in the treatment of Class III malocclu-sions.2,3,13-15 It is essential to reduce the severity of themalocclusion and establish a suitable environment for

jaw growth.2,3 It can not only provide early improvement of the facial prole, which psychosocially

benets patients and their parents, but also reduce thenecessity of orthognathic surgery in the future.15Previ-

ous studies have found that Class III patients treated ata younger age can obtain a greater skeletal compo-

nent.16,17 In addition, the skeletal transverse problemcan be resolved by maxillary disjunction with a palatalexpender. The timing of early intervention should be in

the mixed dentition and before pubertal growth.

10,13,14

Therefore, in this patient, early treatment began right

after she rst came to us; it successfully improved herocclusion and facial appearance.

The early treatment provided a suitable environmentfor her jaw growth, but it could not change her skeletalheredity. Her mandibular excessive growth duringadolescence caused the relapse of the Class III malocclu-

sion and deterioration of her facial appearance. This wasattributed to the hereditary factor in her craniofacialdevelopment. A previous study proved that mandibular

growth, in general, can be redirected instead ofrestrained in most Class III patients.18

Orthodontic camouage is a less-than-ideal therapy,

but it is valid if patients refuse surgery. It is a dilemmato determine the appropriate timing to start treatment.If it is carried out after the completion of facial growth,

more stability can be expected. However, in this period,dental compensation is hard to achieve because of thelimited remodeling of the alveolar bone. Comparatively,

during pubertal growth, the alveolar bone is easier tomodify, and more orthodontic decompensation can beexpected. However, the stability of camouage may

be unpredictable if the patient still has growth potential

when the treatment is nished. In this study, thecomprehensive orthodontic treatment was carried out

when the patient was 12 years old because of her urgentdesire for improvement of her appearance. At that time,the patient had a lot of growth potential, which facili-

tated the alveolar remodeling. After 4 years 8 monthsof camouage treatment, the patient was around 17

years old. Therefore, more treatment stability could beexpected.

The most dramatic changes in this patient were theimprovement of her incisor inclination and the remodel-ing of the anterior alveolae. The incisor movement waspartly controlled by the bracket system and the treat-

ment mechanics.19 During the treatment, we usedlight-force elastics and gradually achieved our goals.The auxiliary rectangular wire (0.017 3 0.025-in

Fig 10. Intraoral progress photographs. During the comprehensive treatment, the mandibular incisors

were gradually uprighted.



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Fig 12. Dental casts after phase 2 treatment.

Fig 11. Facial and intraoral photographs after phase 2 treatment.



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nickel-titanium) in the maxillary arch was used with around main wire (0.016-in stainless steel) and an open-ing spring to create space for the impacted left secondpremolar and to move the anterior segment forward.

Thereafter, the whole maxillary arch (with a 0.019 30.025-in nickel-titanium wire) was used as anchoragefor retraction of the mandibular teeth to limit the dele-terious effects of Class III elastics.

Fig 14. The overall maxillary and mandibular superimpositions of the initial and nal tracings of the

phase 2 treatment.

Fig 13. Cephalometric and panoramic radiographs after phase 2 treatment.



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From the pretreatment vs posttreatment superimpo-sition (Fig 14), A-point (deepest point between ANS andthe maxillary incisal alveolus) and B-point (deepest

point between pogonion and the mandibular incisalalveolus) followed the movement of the incisor roots.In the maxillary arch, the reaction of the distalization

Fig 17. Cephalometric and panoramic radiographs after 2 years of retention.

Fig 18. The overall maxillary and mandibular superimpositions of the posttreatment and the 2-year

follow-up tracings.



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of the

rst molars and the following Class III elasticspushed the anterior teeth forward. The maxillary inci-sors were moved bodily forward with good torque con-trol. Since bone traced the tooth movement,9 the SNAangle increased from 74.5 to 78.1 with the sagittal

improvement of A-point. This remarkable change wascaused by both the maxillary sagittal growth and the

bodily forward movement of the maxillary incisors.Similarly, Goldin19 claimed that a greater rate of A-

point advancement could be produced by labial roottorque in orthodontic treatment compared with normalgrowth. He attributed the change to the greater den-toalveolar effect than the effect on the midsagittal basal

bone.The decompensation of the inclination of the

mandibular incisors should be carried out gently and

gradually to prevent bone loss and gingival recession.The prescription for the mandibular incisors changedto 6 when we placed the brackets upside down inten-tionally. The wire in the mandibular arch was graduallychanged from 0.016 3 0.022-in nickel-titanium to0.019 3 0.025-in nickel-titanium. Meanwhile, short

Class III elastics with a light force (1.5 oz) were worn.Through the interaction between the bracket slots andthe archwires, the lingual root torque of the mandibular

incisors was gradually expressed. The force of the ClassIII elastics prevented the incisors from proclination andretracted the mandibular dentition. In the end, the

mandibular incisors were successfully uprighted anddistalized (Figs 14and 19). B-point was stabilized, andthe SNB angle remained stable (79.3), despite thecontinuous growth of the chin (PO-NB, from 1.0 to

3.1mm) during the phase 2 treatment (Table). Further-more, the reshaping of mandibular anterior region ledto an esthetic contour of the mentolabial fold andtheimprovement of the patient's lower facial prole.20

Janson et al

1

used

biofunctional brackets

withreverse torque prescriptions on the maxillary and mandib-ular incisors to control theproclination of themaxillary in-cisors and the retroclination of the mandibular incisorsand to obtain bodily movement of the incisors. They

used prescriptions of lingual crown torque on the maxil-lary anterior teeth (0) and labial crown torque on themandibular anterior teeth (14) to counteract the ClassIII elastics because they believed that bodily movement

would induce a greater alveolar remodelingresponse.1,19,21 Unlimited movement of the mandibularincisors is not possible because of the restrictionimposed by the symphyseal bone.22 Because the bonesupport in the anterior region of a dental arch is limitedin skeletal Class III patients, severe iatrogenic sequelae of

orthodontic treatment should be considered, consistingof resorption of the labial cortical plate with subsequentgingival recession, dehiscence, or fenestration and length-ening of the clinical crowns of the mandibular incisors orresorption of their lingual cortical plates.6,22,23 Afterobserving the changes in alveolar bone thickness fromretraction of the anterior teeth, Sarikaya et al22 inferred

that light forces and long-term activations to allow thealveolar bone to adapt might be helpful in reducing therisk of adverse effects. Their proposals were exactly what

we did for this patient. The force of Class III elastics weused was about 2 oz (56.7 g), and the comprehensivetreatment took 4 years 8 months. No negative effects

have been seen in this patient.Another reason for the light force we used in Class III

elastics was to prevent extrusion of the maxillary posteriorteeth;this would havecaused a severe backward rotation ofthe mandible. Although this treatment-induced rotation

assists the resolution of the anterior crossbite, the conse-quent increase of facial heightwillcause thefacial estheticsto deteriorate and might cause lip incompetence.24 The

Fig 19. The dramatic changes of the mandibular anterior contour and B-point: A, before comprehen-

sive treatment;B, after orthodontic treatment;C, at the 2-year follow-up.



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patient's mandibular angle (FMA) increased by 3 (from

28.7 to 31.7) during the comprehensive treatment andrelapsed a little during the retention (back to 30.9).

The 2-year follow-up records (Figs 15-17,Table) and

the superimpostions (Fig 18) indicated that the treat-ment results were quite stable. The patient was 19 yearsold with little potential mandibular growth when she

visited us the last time. Therefore, our 2-phase treatmentwas proved successful. We suggested that the patientshould have genioplasty, because it would remarkablyimprove her facial appearance. But she refused it again.

However, this protocol of orthodontic decompensa-tionwith dentoalveolar remodeling in a growing ClassIII patient and then genioplasty in adulthood could be

considered in the future.

CONCLUSIONS

A skeletal Class III girl was successfully treated in 2phases without surgery. In the comprehensive orthodon-tic treatment, orthodontic decompensationand Class

III correction were achieved by gradual dentoalveolarremodeling during the patient's growth. Propertreatment mechanics and sufcient treatment time

were the keys to success.

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