Case ReportDiagnosis and Treatment of Pseudo-Class III Malocclusion
Ariel Reyes1 Luis Serret23 Marcos Peguero34 and Orlando Tanaka5
1 School of Health and Biosciences Pontifıcia Universidade Catolica do Parana Brazil2 Universidad Intercontinental Mexico Mexico3 Private Practice in Santo Domingo Dominican Republic4 Pontifıcia Universidade Catolica do Rio de Janeiro Brazil5 Graduate Program in Orthodontics School of Health and Biosciences Pontifıcia Universidade Catolica do ParanaRua Imaculada Conceicao 1155 Bairro Prado Velho 80215-901 Curitiba PR Brazil
Correspondence should be addressed to Orlando Tanaka tanakaomgmailcom
Received 11 September 2014 Revised 6 November 2014 Accepted 14 November 2014 Published 24 November 2014
Academic Editor Mehmet Ozgur Sayin
Copyright copy 2014 Ariel Reyes et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited
Pseudo-Class III malocclusion is characterized by the presence of an anterior crossbite due to a forward functional displacement ofthemandible inmost cases themaxillary incisors present some degree of retroclination and themandibular incisors are proclinedVarious types of appliances have been described in the literature for the early treatment of pseudo-Class III malocclusion Theobjectives of this paper are to demonstrate the importance of making the differential diagnosis between a skeletal and a pseudo-Class III malocclusion and to describe the correction of an anterior crossbite The association of maxillary expansion and a 2 times 4appliance can successfully be used to correct anterior crossbites
1 Introduction
Class III malocclusion was originally described by Angle as acondition in which the relationship of the jaws is abnormaland all of the mandibular teeth occlude mesial to normalby the width of one bicuspid or more [1] The etiology isassociated with environmental and genetic factors and ahigher incidence has been observed in an Asian population[2] The etiological factors of this malocclusion have beenclassified into three groups (a) functional which includesabnormal tongue position nasal-respiratory problems andneuromuscular conditions (b) skeletal such as during max-illary transversal deficiency and (c) dental which includesectopic eruption of the maxillary central incisors and earlyloss of the deciduous molars [2 3]
Pseudo-Class III malocclusion is characterized by thepresence of an anterior crossbite due to a forward functionaldisplacement of the mandible In the mixed dentition themesial step cannot exceed 3mm the maxillary incisorspresent retroclination and the mandibular incisors are pro-clined and spaced [3 4] When patients are guided intoa centric relationship they usually show an end-to-end
incisor relationship involving the performance of a forwardfunctional mandibular shift due to a muscular reflex so thatthe posterior teeth are able to occlude It is for this reason thatthis type of malocclusion has been described as a pseudo- orfunctional Class III malocclusion [2 3 5 6]
In most cases retroclined maxillary incisors are the maincause of pseudo-Class III malocclusion [6] Often a molarClass I relationship is present with a normal mandibularappearance and a straight facial profile disguising the skele-tal discrepancy that may exist [2] However patients withskeletal Class III malocclusions show a posterior crossbiteand maintain their molar relationship when guided to acentric relationship [3] Correction of the anterior crossbitemust be carried out as soon as it is detected to increase theorthopedic effects thereby increasing the long-term stabilityof the treatment results [3]
2 Case Presentation
A 10-and-a-half-year-old girl was referred by her dentist withthe following chief complaint ldquoMy mandible is forward and
Hindawi Publishing CorporationCase Reports in DentistryVolume 2014 Article ID 652936 6 pageshttpdxdoiorg1011552014652936
2 Case Reports in Dentistry
Figure 1 Pretreatment photographs
my upper teeth look uglyrdquo The extraoral facial examina-tion revealed a straight profile lower lip protrusion and adolichofacial pattern The intraoral evaluation revealed latemixed dentition due to the presence of both the deciduousmaxillary second molars and the deciduous mandibularright second molar the absence of maxillary deciduouscanines due to prior extraction a Class I molar relationshipanterior crossbite of themaxillary central and lateral incisorscrowding in both arches and a lack of space for the maxillarycanines to erupt (Figure 1)
The panoramic radiograph revealed that the mandibularright second premolar was mesially angulated and that theeruption sequence was favorable and an occlusal radiograph
indicated that the tooth was actually in a transalveolarposition with the crown located lingually The cephalometricanalysis revealed a Class I skeletal relationship (ANB = 2∘)a clockwise growth pattern (SNGoGn = 40∘ FMA = 29∘)protrusion of the mandibular incisors (IMPA = 99∘ 1NB =35∘) retrusion of the maxillary incisors (1NA = 18∘ 1-NA =1mm) and protrusion of the lower lip (Ricketts E-line =3mm) (Figure 2 Table 1) Based on these diagnostic findingsit was concluded that the patient presented a skeletal Class Irelationship
The objectives were to maintain the Class I molarrelationship correct the anterior crossbite and augmentthe maxillary arch perimeter allowing guided eruption
Case Reports in Dentistry 3
Figure 2 Lateral cephalogram radiograph
(a)
(b)
Figure 3 (a) Maxillary 2 times 4 associated with a mandibular bite plane (b) treatment progress 001710158401015840 times 002510158401015840 SS
of the maxillary canines and orthodontic traction of themandibular right second premolar while taking advantage ofthe E-space
The diagnosis of skeletal Class I improved her progno-sis and correction of the anterior crossbite was attemptedthrough maxillary expansion associated with a fixed 2 times4 appliance Other options included the following (1) aremovable appliance with a Z-spring to procline the max-illary incisors labially (2) an angulated bite plane and (3)functional appliances although the lack of cooperation ofsome patients and the inability of the appliances to promotecorrect alignment and leveling are the biggest disadvantages
of these appliances To achieve good alignment and levelinga fixed appliance must be used [2 5] Using a facial mask wasnot considered because of the age of the patient and the factthat the harmonic basal bone relationship was within normallimits
3 Treatment Progress
The patient was first submitted to a rapid maxillary expan-sion once finished this first phase we bonded a pread-justed Edgewise 001810158401015840 slot 2 times 4 appliance with an initial001410158401015840 NiTi arch wire in the maxillary arch associated
4 Case Reports in Dentistry
Figure 4 Posttreatment photographs and radiographs
with a removable bite plane in the mandibular arch Aftercorrecting the anterior crossbite the use of the bite plane wassuspended andmaxillary sequential bonding was performedvisualizing a corrective orthodontic treatment in the secondphase A heat-activated 001610158401015840times 002210158401015840 NiTi arch wire wasplaced as initial arch followed by a superelastic 001710158401015840 times002510158401015840 NiTi arch wire The treatment of the mandibular archbegan two months after inserting the maxillary 001710158401015840 times002510158401015840 NiTi arch the arch wire sequence in the mandibular
arch followed the same pattern Both arches finished with a001710158401015840 times 002510158401015840 SS (Figures 3(a) and 3(b))
At the end of the treatment the pseudo-Class III relation-ship was compensated during the second phase The spacegained with the maxillary expansion and maxillary incisorsprotrusion helped in the eruption of the maxillary caninesand the correction of the anterior crossbite In themandibulararch the position of the transalveolar right second premolarself-corrected and erupted after extraction of the mandibular
Case Reports in Dentistry 5
deciduous right second molar avoiding the need for thesurgical exposure planned at the beginning of treatmentFacially the treatment did not change her growth pattern andthe Class III characteristics were maintained (Figure 4)
4 Discussion
Treatment of a pseudo-Class III malocclusion must be per-formed as soon as it is detected and should be considered asa Class III malocclusion [4] however the clinician is unfor-tunately not always able to evaluate the patient during thedevelopmental stage of this type of malocclusion Anteriorcrossbite has been associated with a variety of complicationssuch as gingival recession of the lower incisors incisalwear and worsening of the growth pattern correcting ananterior crossbite consequently increases the maxillary archperimeter offering more space for the canines and premolarsto erupt and therefore a more stable orthopedic result [4ndash8]
The functional appliances used to treat Class III mal-occlusion work by permitting the eruption of the maxillarymolars and maintaining the mandibular ones in positionleading to an occlusal plane rotation that helps shift themolar relationship from Class III to Class I [9] Face maskprotraction creates a counterclockwise rotation of themaxillaand a clockwise rotation of the mandible while increasing theinferior facial height and turning the patientrsquos profile moreconvex [4]
When treating young patients with anterior crossbite inmixed dentition better results can be achieved through theassociation ofmaxillary expansion due to orthopedic stabilityand the movement of the maxilla down and forward [10] In84 of cases a self-correction could be expected without theneed for any other type of appliance [11] The association ofmaxillary expansion with fixed appliances improves the archperimeter reducing the number of extractions in patientswith slight tomild crowdingThe increase has been quantifiedto span up to 60mm in themaxillary arch [12] Other advan-tages of fixed appliances include better three-dimensionalcontrol of the tooth and the release of continuous forces[8] Our patient benefitted from this combination becausethe space gained with the maxillary expansion and incisorsprotrusion helped for the eruption of the canines and thecorrection of the anterior crossbite in this compensatorytreatment where the sagittal relationship was maintained butthe maxillary incisors where protruded (1NA = 33∘ 1-NA =8mm) Table 1
The correction of pseudo-Class III malocclusion with theuse of a 2 times 4 appliance has been successful in nearly 100of the cases without requiring a second phase for positiveoverjet to be obtained after treatment This success is dueto the advancement of point A which remains stable overthe long term [6] but it is important to remember thatthese patients maintain their facial character and tendencyof growth resembling to nontreated ones [4] In our casethe patient had cephalometric values of a skeletal Class Irelationship (ANB = 1∘) which was not reflected on her faceshe maintained a Class III profile
Correctly diagnosing a pseudo-Class III malocclusionmakes a difference in the orthodontic treatment plan
The association of maxillary expansion and a 2 times 4 appliancecan be successful during the correction of anterior crossbites
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] E H Angle ldquoClassification of malocclusionrdquo The Dental Cos-mos vol 41 pp 248ndash264 1899
[2] A Giancotti A Maselli G Mampieri and E Spano ldquoPseudo-Class IIImalocclusion treatmentwith Baltersrsquo Bionatorrdquo Journalof Orthodontics vol 30 no 3 pp 203ndash215 2003
[3] D B Raveli P C R Chiavini R F Paulin H B Jacob A dosSantos-Pinto and L P Sampaio ldquoTratamento de um Caso dePseudo-classe III por Meio de Aparelho Fixordquo Jornal Brasileirode Ortodontia amp Ortopedia Facial vol 9 pp 356ndash362 2004
[4] P K Turley ldquoTreatment of the class III malocclusion with max-illary expansion and protractionrdquo Seminars inOrthodontics vol13 no 3 pp 143ndash157 2007
[5] S J Bowman ldquoA quick fix for pseudo-class III correctionrdquoJournal of Clinical Orthodontics vol 42 no 12 pp 691ndash7272008
[6] U Hagg A Tse M Bendeus and A B M Rabie ldquoA follow-upstudy of early treatment of pseudo class III malocclusionrdquoAngleOrthodontist vol 74 no 4 pp 465ndash472 2004
[7] M R de Almeida R R de Almeida P V P Oltramari-NavarroA C D C F Conti R D L Navarro and J G D D CamacholdquoEarly treatment of Class III malocclusion 10-year clinicalfollow-uprdquo Journal of AppliedOral Science vol 19 no 4 pp 431ndash439 2011
[8] O M Tanaka J V B Maciel T B Kreia A L R Avila andM M Pithon ldquoThe anterior dental cross- bite the paradigmof interception in orthodonticsrdquo Revista de Clınica e PesquisaOdontologica vol 6 pp 71ndash78 2010
6 Case Reports in Dentistry
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
my upper teeth look uglyrdquo The extraoral facial examina-tion revealed a straight profile lower lip protrusion and adolichofacial pattern The intraoral evaluation revealed latemixed dentition due to the presence of both the deciduousmaxillary second molars and the deciduous mandibularright second molar the absence of maxillary deciduouscanines due to prior extraction a Class I molar relationshipanterior crossbite of themaxillary central and lateral incisorscrowding in both arches and a lack of space for the maxillarycanines to erupt (Figure 1)
The panoramic radiograph revealed that the mandibularright second premolar was mesially angulated and that theeruption sequence was favorable and an occlusal radiograph
indicated that the tooth was actually in a transalveolarposition with the crown located lingually The cephalometricanalysis revealed a Class I skeletal relationship (ANB = 2∘)a clockwise growth pattern (SNGoGn = 40∘ FMA = 29∘)protrusion of the mandibular incisors (IMPA = 99∘ 1NB =35∘) retrusion of the maxillary incisors (1NA = 18∘ 1-NA =1mm) and protrusion of the lower lip (Ricketts E-line =3mm) (Figure 2 Table 1) Based on these diagnostic findingsit was concluded that the patient presented a skeletal Class Irelationship
The objectives were to maintain the Class I molarrelationship correct the anterior crossbite and augmentthe maxillary arch perimeter allowing guided eruption
Case Reports in Dentistry 3
Figure 2 Lateral cephalogram radiograph
(a)
(b)
Figure 3 (a) Maxillary 2 times 4 associated with a mandibular bite plane (b) treatment progress 001710158401015840 times 002510158401015840 SS
of the maxillary canines and orthodontic traction of themandibular right second premolar while taking advantage ofthe E-space
The diagnosis of skeletal Class I improved her progno-sis and correction of the anterior crossbite was attemptedthrough maxillary expansion associated with a fixed 2 times4 appliance Other options included the following (1) aremovable appliance with a Z-spring to procline the max-illary incisors labially (2) an angulated bite plane and (3)functional appliances although the lack of cooperation ofsome patients and the inability of the appliances to promotecorrect alignment and leveling are the biggest disadvantages
of these appliances To achieve good alignment and levelinga fixed appliance must be used [2 5] Using a facial mask wasnot considered because of the age of the patient and the factthat the harmonic basal bone relationship was within normallimits
3 Treatment Progress
The patient was first submitted to a rapid maxillary expan-sion once finished this first phase we bonded a pread-justed Edgewise 001810158401015840 slot 2 times 4 appliance with an initial001410158401015840 NiTi arch wire in the maxillary arch associated
4 Case Reports in Dentistry
Figure 4 Posttreatment photographs and radiographs
with a removable bite plane in the mandibular arch Aftercorrecting the anterior crossbite the use of the bite plane wassuspended andmaxillary sequential bonding was performedvisualizing a corrective orthodontic treatment in the secondphase A heat-activated 001610158401015840times 002210158401015840 NiTi arch wire wasplaced as initial arch followed by a superelastic 001710158401015840 times002510158401015840 NiTi arch wire The treatment of the mandibular archbegan two months after inserting the maxillary 001710158401015840 times002510158401015840 NiTi arch the arch wire sequence in the mandibular
arch followed the same pattern Both arches finished with a001710158401015840 times 002510158401015840 SS (Figures 3(a) and 3(b))
At the end of the treatment the pseudo-Class III relation-ship was compensated during the second phase The spacegained with the maxillary expansion and maxillary incisorsprotrusion helped in the eruption of the maxillary caninesand the correction of the anterior crossbite In themandibulararch the position of the transalveolar right second premolarself-corrected and erupted after extraction of the mandibular
Case Reports in Dentistry 5
deciduous right second molar avoiding the need for thesurgical exposure planned at the beginning of treatmentFacially the treatment did not change her growth pattern andthe Class III characteristics were maintained (Figure 4)
4 Discussion
Treatment of a pseudo-Class III malocclusion must be per-formed as soon as it is detected and should be considered asa Class III malocclusion [4] however the clinician is unfor-tunately not always able to evaluate the patient during thedevelopmental stage of this type of malocclusion Anteriorcrossbite has been associated with a variety of complicationssuch as gingival recession of the lower incisors incisalwear and worsening of the growth pattern correcting ananterior crossbite consequently increases the maxillary archperimeter offering more space for the canines and premolarsto erupt and therefore a more stable orthopedic result [4ndash8]
The functional appliances used to treat Class III mal-occlusion work by permitting the eruption of the maxillarymolars and maintaining the mandibular ones in positionleading to an occlusal plane rotation that helps shift themolar relationship from Class III to Class I [9] Face maskprotraction creates a counterclockwise rotation of themaxillaand a clockwise rotation of the mandible while increasing theinferior facial height and turning the patientrsquos profile moreconvex [4]
When treating young patients with anterior crossbite inmixed dentition better results can be achieved through theassociation ofmaxillary expansion due to orthopedic stabilityand the movement of the maxilla down and forward [10] In84 of cases a self-correction could be expected without theneed for any other type of appliance [11] The association ofmaxillary expansion with fixed appliances improves the archperimeter reducing the number of extractions in patientswith slight tomild crowdingThe increase has been quantifiedto span up to 60mm in themaxillary arch [12] Other advan-tages of fixed appliances include better three-dimensionalcontrol of the tooth and the release of continuous forces[8] Our patient benefitted from this combination becausethe space gained with the maxillary expansion and incisorsprotrusion helped for the eruption of the canines and thecorrection of the anterior crossbite in this compensatorytreatment where the sagittal relationship was maintained butthe maxillary incisors where protruded (1NA = 33∘ 1-NA =8mm) Table 1
The correction of pseudo-Class III malocclusion with theuse of a 2 times 4 appliance has been successful in nearly 100of the cases without requiring a second phase for positiveoverjet to be obtained after treatment This success is dueto the advancement of point A which remains stable overthe long term [6] but it is important to remember thatthese patients maintain their facial character and tendencyof growth resembling to nontreated ones [4] In our casethe patient had cephalometric values of a skeletal Class Irelationship (ANB = 1∘) which was not reflected on her faceshe maintained a Class III profile
Correctly diagnosing a pseudo-Class III malocclusionmakes a difference in the orthodontic treatment plan
The association of maxillary expansion and a 2 times 4 appliancecan be successful during the correction of anterior crossbites
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] E H Angle ldquoClassification of malocclusionrdquo The Dental Cos-mos vol 41 pp 248ndash264 1899
[2] A Giancotti A Maselli G Mampieri and E Spano ldquoPseudo-Class IIImalocclusion treatmentwith Baltersrsquo Bionatorrdquo Journalof Orthodontics vol 30 no 3 pp 203ndash215 2003
[3] D B Raveli P C R Chiavini R F Paulin H B Jacob A dosSantos-Pinto and L P Sampaio ldquoTratamento de um Caso dePseudo-classe III por Meio de Aparelho Fixordquo Jornal Brasileirode Ortodontia amp Ortopedia Facial vol 9 pp 356ndash362 2004
[4] P K Turley ldquoTreatment of the class III malocclusion with max-illary expansion and protractionrdquo Seminars inOrthodontics vol13 no 3 pp 143ndash157 2007
[5] S J Bowman ldquoA quick fix for pseudo-class III correctionrdquoJournal of Clinical Orthodontics vol 42 no 12 pp 691ndash7272008
[6] U Hagg A Tse M Bendeus and A B M Rabie ldquoA follow-upstudy of early treatment of pseudo class III malocclusionrdquoAngleOrthodontist vol 74 no 4 pp 465ndash472 2004
[7] M R de Almeida R R de Almeida P V P Oltramari-NavarroA C D C F Conti R D L Navarro and J G D D CamacholdquoEarly treatment of Class III malocclusion 10-year clinicalfollow-uprdquo Journal of AppliedOral Science vol 19 no 4 pp 431ndash439 2011
[8] O M Tanaka J V B Maciel T B Kreia A L R Avila andM M Pithon ldquoThe anterior dental cross- bite the paradigmof interception in orthodonticsrdquo Revista de Clınica e PesquisaOdontologica vol 6 pp 71ndash78 2010
6 Case Reports in Dentistry
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
Figure 3 (a) Maxillary 2 times 4 associated with a mandibular bite plane (b) treatment progress 001710158401015840 times 002510158401015840 SS
of the maxillary canines and orthodontic traction of themandibular right second premolar while taking advantage ofthe E-space
The diagnosis of skeletal Class I improved her progno-sis and correction of the anterior crossbite was attemptedthrough maxillary expansion associated with a fixed 2 times4 appliance Other options included the following (1) aremovable appliance with a Z-spring to procline the max-illary incisors labially (2) an angulated bite plane and (3)functional appliances although the lack of cooperation ofsome patients and the inability of the appliances to promotecorrect alignment and leveling are the biggest disadvantages
of these appliances To achieve good alignment and levelinga fixed appliance must be used [2 5] Using a facial mask wasnot considered because of the age of the patient and the factthat the harmonic basal bone relationship was within normallimits
3 Treatment Progress
The patient was first submitted to a rapid maxillary expan-sion once finished this first phase we bonded a pread-justed Edgewise 001810158401015840 slot 2 times 4 appliance with an initial001410158401015840 NiTi arch wire in the maxillary arch associated
4 Case Reports in Dentistry
Figure 4 Posttreatment photographs and radiographs
with a removable bite plane in the mandibular arch Aftercorrecting the anterior crossbite the use of the bite plane wassuspended andmaxillary sequential bonding was performedvisualizing a corrective orthodontic treatment in the secondphase A heat-activated 001610158401015840times 002210158401015840 NiTi arch wire wasplaced as initial arch followed by a superelastic 001710158401015840 times002510158401015840 NiTi arch wire The treatment of the mandibular archbegan two months after inserting the maxillary 001710158401015840 times002510158401015840 NiTi arch the arch wire sequence in the mandibular
arch followed the same pattern Both arches finished with a001710158401015840 times 002510158401015840 SS (Figures 3(a) and 3(b))
At the end of the treatment the pseudo-Class III relation-ship was compensated during the second phase The spacegained with the maxillary expansion and maxillary incisorsprotrusion helped in the eruption of the maxillary caninesand the correction of the anterior crossbite In themandibulararch the position of the transalveolar right second premolarself-corrected and erupted after extraction of the mandibular
Case Reports in Dentistry 5
deciduous right second molar avoiding the need for thesurgical exposure planned at the beginning of treatmentFacially the treatment did not change her growth pattern andthe Class III characteristics were maintained (Figure 4)
4 Discussion
Treatment of a pseudo-Class III malocclusion must be per-formed as soon as it is detected and should be considered asa Class III malocclusion [4] however the clinician is unfor-tunately not always able to evaluate the patient during thedevelopmental stage of this type of malocclusion Anteriorcrossbite has been associated with a variety of complicationssuch as gingival recession of the lower incisors incisalwear and worsening of the growth pattern correcting ananterior crossbite consequently increases the maxillary archperimeter offering more space for the canines and premolarsto erupt and therefore a more stable orthopedic result [4ndash8]
The functional appliances used to treat Class III mal-occlusion work by permitting the eruption of the maxillarymolars and maintaining the mandibular ones in positionleading to an occlusal plane rotation that helps shift themolar relationship from Class III to Class I [9] Face maskprotraction creates a counterclockwise rotation of themaxillaand a clockwise rotation of the mandible while increasing theinferior facial height and turning the patientrsquos profile moreconvex [4]
When treating young patients with anterior crossbite inmixed dentition better results can be achieved through theassociation ofmaxillary expansion due to orthopedic stabilityand the movement of the maxilla down and forward [10] In84 of cases a self-correction could be expected without theneed for any other type of appliance [11] The association ofmaxillary expansion with fixed appliances improves the archperimeter reducing the number of extractions in patientswith slight tomild crowdingThe increase has been quantifiedto span up to 60mm in themaxillary arch [12] Other advan-tages of fixed appliances include better three-dimensionalcontrol of the tooth and the release of continuous forces[8] Our patient benefitted from this combination becausethe space gained with the maxillary expansion and incisorsprotrusion helped for the eruption of the canines and thecorrection of the anterior crossbite in this compensatorytreatment where the sagittal relationship was maintained butthe maxillary incisors where protruded (1NA = 33∘ 1-NA =8mm) Table 1
The correction of pseudo-Class III malocclusion with theuse of a 2 times 4 appliance has been successful in nearly 100of the cases without requiring a second phase for positiveoverjet to be obtained after treatment This success is dueto the advancement of point A which remains stable overthe long term [6] but it is important to remember thatthese patients maintain their facial character and tendencyof growth resembling to nontreated ones [4] In our casethe patient had cephalometric values of a skeletal Class Irelationship (ANB = 1∘) which was not reflected on her faceshe maintained a Class III profile
Correctly diagnosing a pseudo-Class III malocclusionmakes a difference in the orthodontic treatment plan
The association of maxillary expansion and a 2 times 4 appliancecan be successful during the correction of anterior crossbites
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] E H Angle ldquoClassification of malocclusionrdquo The Dental Cos-mos vol 41 pp 248ndash264 1899
[2] A Giancotti A Maselli G Mampieri and E Spano ldquoPseudo-Class IIImalocclusion treatmentwith Baltersrsquo Bionatorrdquo Journalof Orthodontics vol 30 no 3 pp 203ndash215 2003
[3] D B Raveli P C R Chiavini R F Paulin H B Jacob A dosSantos-Pinto and L P Sampaio ldquoTratamento de um Caso dePseudo-classe III por Meio de Aparelho Fixordquo Jornal Brasileirode Ortodontia amp Ortopedia Facial vol 9 pp 356ndash362 2004
[4] P K Turley ldquoTreatment of the class III malocclusion with max-illary expansion and protractionrdquo Seminars inOrthodontics vol13 no 3 pp 143ndash157 2007
[5] S J Bowman ldquoA quick fix for pseudo-class III correctionrdquoJournal of Clinical Orthodontics vol 42 no 12 pp 691ndash7272008
[6] U Hagg A Tse M Bendeus and A B M Rabie ldquoA follow-upstudy of early treatment of pseudo class III malocclusionrdquoAngleOrthodontist vol 74 no 4 pp 465ndash472 2004
[7] M R de Almeida R R de Almeida P V P Oltramari-NavarroA C D C F Conti R D L Navarro and J G D D CamacholdquoEarly treatment of Class III malocclusion 10-year clinicalfollow-uprdquo Journal of AppliedOral Science vol 19 no 4 pp 431ndash439 2011
[8] O M Tanaka J V B Maciel T B Kreia A L R Avila andM M Pithon ldquoThe anterior dental cross- bite the paradigmof interception in orthodonticsrdquo Revista de Clınica e PesquisaOdontologica vol 6 pp 71ndash78 2010
6 Case Reports in Dentistry
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
Figure 4 Posttreatment photographs and radiographs
with a removable bite plane in the mandibular arch Aftercorrecting the anterior crossbite the use of the bite plane wassuspended andmaxillary sequential bonding was performedvisualizing a corrective orthodontic treatment in the secondphase A heat-activated 001610158401015840times 002210158401015840 NiTi arch wire wasplaced as initial arch followed by a superelastic 001710158401015840 times002510158401015840 NiTi arch wire The treatment of the mandibular archbegan two months after inserting the maxillary 001710158401015840 times002510158401015840 NiTi arch the arch wire sequence in the mandibular
arch followed the same pattern Both arches finished with a001710158401015840 times 002510158401015840 SS (Figures 3(a) and 3(b))
At the end of the treatment the pseudo-Class III relation-ship was compensated during the second phase The spacegained with the maxillary expansion and maxillary incisorsprotrusion helped in the eruption of the maxillary caninesand the correction of the anterior crossbite In themandibulararch the position of the transalveolar right second premolarself-corrected and erupted after extraction of the mandibular
Case Reports in Dentistry 5
deciduous right second molar avoiding the need for thesurgical exposure planned at the beginning of treatmentFacially the treatment did not change her growth pattern andthe Class III characteristics were maintained (Figure 4)
4 Discussion
Treatment of a pseudo-Class III malocclusion must be per-formed as soon as it is detected and should be considered asa Class III malocclusion [4] however the clinician is unfor-tunately not always able to evaluate the patient during thedevelopmental stage of this type of malocclusion Anteriorcrossbite has been associated with a variety of complicationssuch as gingival recession of the lower incisors incisalwear and worsening of the growth pattern correcting ananterior crossbite consequently increases the maxillary archperimeter offering more space for the canines and premolarsto erupt and therefore a more stable orthopedic result [4ndash8]
The functional appliances used to treat Class III mal-occlusion work by permitting the eruption of the maxillarymolars and maintaining the mandibular ones in positionleading to an occlusal plane rotation that helps shift themolar relationship from Class III to Class I [9] Face maskprotraction creates a counterclockwise rotation of themaxillaand a clockwise rotation of the mandible while increasing theinferior facial height and turning the patientrsquos profile moreconvex [4]
When treating young patients with anterior crossbite inmixed dentition better results can be achieved through theassociation ofmaxillary expansion due to orthopedic stabilityand the movement of the maxilla down and forward [10] In84 of cases a self-correction could be expected without theneed for any other type of appliance [11] The association ofmaxillary expansion with fixed appliances improves the archperimeter reducing the number of extractions in patientswith slight tomild crowdingThe increase has been quantifiedto span up to 60mm in themaxillary arch [12] Other advan-tages of fixed appliances include better three-dimensionalcontrol of the tooth and the release of continuous forces[8] Our patient benefitted from this combination becausethe space gained with the maxillary expansion and incisorsprotrusion helped for the eruption of the canines and thecorrection of the anterior crossbite in this compensatorytreatment where the sagittal relationship was maintained butthe maxillary incisors where protruded (1NA = 33∘ 1-NA =8mm) Table 1
The correction of pseudo-Class III malocclusion with theuse of a 2 times 4 appliance has been successful in nearly 100of the cases without requiring a second phase for positiveoverjet to be obtained after treatment This success is dueto the advancement of point A which remains stable overthe long term [6] but it is important to remember thatthese patients maintain their facial character and tendencyof growth resembling to nontreated ones [4] In our casethe patient had cephalometric values of a skeletal Class Irelationship (ANB = 1∘) which was not reflected on her faceshe maintained a Class III profile
Correctly diagnosing a pseudo-Class III malocclusionmakes a difference in the orthodontic treatment plan
The association of maxillary expansion and a 2 times 4 appliancecan be successful during the correction of anterior crossbites
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] E H Angle ldquoClassification of malocclusionrdquo The Dental Cos-mos vol 41 pp 248ndash264 1899
[2] A Giancotti A Maselli G Mampieri and E Spano ldquoPseudo-Class IIImalocclusion treatmentwith Baltersrsquo Bionatorrdquo Journalof Orthodontics vol 30 no 3 pp 203ndash215 2003
[3] D B Raveli P C R Chiavini R F Paulin H B Jacob A dosSantos-Pinto and L P Sampaio ldquoTratamento de um Caso dePseudo-classe III por Meio de Aparelho Fixordquo Jornal Brasileirode Ortodontia amp Ortopedia Facial vol 9 pp 356ndash362 2004
[4] P K Turley ldquoTreatment of the class III malocclusion with max-illary expansion and protractionrdquo Seminars inOrthodontics vol13 no 3 pp 143ndash157 2007
[5] S J Bowman ldquoA quick fix for pseudo-class III correctionrdquoJournal of Clinical Orthodontics vol 42 no 12 pp 691ndash7272008
[6] U Hagg A Tse M Bendeus and A B M Rabie ldquoA follow-upstudy of early treatment of pseudo class III malocclusionrdquoAngleOrthodontist vol 74 no 4 pp 465ndash472 2004
[7] M R de Almeida R R de Almeida P V P Oltramari-NavarroA C D C F Conti R D L Navarro and J G D D CamacholdquoEarly treatment of Class III malocclusion 10-year clinicalfollow-uprdquo Journal of AppliedOral Science vol 19 no 4 pp 431ndash439 2011
[8] O M Tanaka J V B Maciel T B Kreia A L R Avila andM M Pithon ldquoThe anterior dental cross- bite the paradigmof interception in orthodonticsrdquo Revista de Clınica e PesquisaOdontologica vol 6 pp 71ndash78 2010
6 Case Reports in Dentistry
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
deciduous right second molar avoiding the need for thesurgical exposure planned at the beginning of treatmentFacially the treatment did not change her growth pattern andthe Class III characteristics were maintained (Figure 4)
4 Discussion
Treatment of a pseudo-Class III malocclusion must be per-formed as soon as it is detected and should be considered asa Class III malocclusion [4] however the clinician is unfor-tunately not always able to evaluate the patient during thedevelopmental stage of this type of malocclusion Anteriorcrossbite has been associated with a variety of complicationssuch as gingival recession of the lower incisors incisalwear and worsening of the growth pattern correcting ananterior crossbite consequently increases the maxillary archperimeter offering more space for the canines and premolarsto erupt and therefore a more stable orthopedic result [4ndash8]
The functional appliances used to treat Class III mal-occlusion work by permitting the eruption of the maxillarymolars and maintaining the mandibular ones in positionleading to an occlusal plane rotation that helps shift themolar relationship from Class III to Class I [9] Face maskprotraction creates a counterclockwise rotation of themaxillaand a clockwise rotation of the mandible while increasing theinferior facial height and turning the patientrsquos profile moreconvex [4]
When treating young patients with anterior crossbite inmixed dentition better results can be achieved through theassociation ofmaxillary expansion due to orthopedic stabilityand the movement of the maxilla down and forward [10] In84 of cases a self-correction could be expected without theneed for any other type of appliance [11] The association ofmaxillary expansion with fixed appliances improves the archperimeter reducing the number of extractions in patientswith slight tomild crowdingThe increase has been quantifiedto span up to 60mm in themaxillary arch [12] Other advan-tages of fixed appliances include better three-dimensionalcontrol of the tooth and the release of continuous forces[8] Our patient benefitted from this combination becausethe space gained with the maxillary expansion and incisorsprotrusion helped for the eruption of the canines and thecorrection of the anterior crossbite in this compensatorytreatment where the sagittal relationship was maintained butthe maxillary incisors where protruded (1NA = 33∘ 1-NA =8mm) Table 1
The correction of pseudo-Class III malocclusion with theuse of a 2 times 4 appliance has been successful in nearly 100of the cases without requiring a second phase for positiveoverjet to be obtained after treatment This success is dueto the advancement of point A which remains stable overthe long term [6] but it is important to remember thatthese patients maintain their facial character and tendencyof growth resembling to nontreated ones [4] In our casethe patient had cephalometric values of a skeletal Class Irelationship (ANB = 1∘) which was not reflected on her faceshe maintained a Class III profile
Correctly diagnosing a pseudo-Class III malocclusionmakes a difference in the orthodontic treatment plan
The association of maxillary expansion and a 2 times 4 appliancecan be successful during the correction of anterior crossbites
Conflict of Interests
The authors declare that there is no conflict of interestsregarding the publication of this paper
References
[1] E H Angle ldquoClassification of malocclusionrdquo The Dental Cos-mos vol 41 pp 248ndash264 1899
[2] A Giancotti A Maselli G Mampieri and E Spano ldquoPseudo-Class IIImalocclusion treatmentwith Baltersrsquo Bionatorrdquo Journalof Orthodontics vol 30 no 3 pp 203ndash215 2003
[3] D B Raveli P C R Chiavini R F Paulin H B Jacob A dosSantos-Pinto and L P Sampaio ldquoTratamento de um Caso dePseudo-classe III por Meio de Aparelho Fixordquo Jornal Brasileirode Ortodontia amp Ortopedia Facial vol 9 pp 356ndash362 2004
[4] P K Turley ldquoTreatment of the class III malocclusion with max-illary expansion and protractionrdquo Seminars inOrthodontics vol13 no 3 pp 143ndash157 2007
[5] S J Bowman ldquoA quick fix for pseudo-class III correctionrdquoJournal of Clinical Orthodontics vol 42 no 12 pp 691ndash7272008
[6] U Hagg A Tse M Bendeus and A B M Rabie ldquoA follow-upstudy of early treatment of pseudo class III malocclusionrdquoAngleOrthodontist vol 74 no 4 pp 465ndash472 2004
[7] M R de Almeida R R de Almeida P V P Oltramari-NavarroA C D C F Conti R D L Navarro and J G D D CamacholdquoEarly treatment of Class III malocclusion 10-year clinicalfollow-uprdquo Journal of AppliedOral Science vol 19 no 4 pp 431ndash439 2011
[8] O M Tanaka J V B Maciel T B Kreia A L R Avila andM M Pithon ldquoThe anterior dental cross- bite the paradigmof interception in orthodonticsrdquo Revista de Clınica e PesquisaOdontologica vol 6 pp 71ndash78 2010
6 Case Reports in Dentistry
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
[9] J E Bilodeau ldquoNonsurgical treatment of a Class III patientwith a lateral open-bite malocclusionrdquo American Journal ofOrthodontics and Dentofacial Orthopedics vol 140 no 6 pp861ndash868 2011
[10] A Haas ldquoRapid expansion of the maxillary dental arch andnasal cavity by opening themidpalatal suturerdquoTheAngle Ortho-dontist vol 31 pp 73ndash90 1961
[11] M Rosa P Lucchi LMariani andA Caprioglio ldquoSpontaneouscorrection of anterior crossbite by RPE anchored on deciduousteeth in the early mixed dentitionrdquo European Journal of Paedi-atric Dentistry vol 13 no 3 pp 176ndash180 2012
[12] J A McNamara Jr ldquoLong-term adaptations to changes in thetransverse dimension in children and adolescents an overviewrdquoAmerican Journal of Orthodontics and Dentofacial Orthopedicsvol 129 no 4 pp S71ndashS74 2006
![Pseudo Limits, Biadjoints, and Pseudo Algebras: Categorical ...arXiv:math/0408298v4 [math.CT] 18 Oct 2006 Pseudo Limits, Biadjoints, and Pseudo Algebras: Categorical Foundations of](https://static.documents.pub/doc/80x56/60a7a6d20b1ec1029337c248/pseudo-limits-biadjoints-and-pseudo-algebras-categorical-arxivmath0408298v4.jpg)
