GOOD MORNING

CLASS III MALOCCLUSIONPresented by:Dr. Khushbu AgrawalGuided by:Dr. Suresh KanganeDr. Anand AmbekarDr. Pravinkumar Marure Dr. Yatishkumar JoshiDr. Chaitanya Khanapure

2

CONTENTINTRODUCTIONCLASSIFICATIONETIOLOGYCLINICAL FEATURESDIAGNOSIS TREATMENT

3

INTRODUCTIONEdward Angle classified malocclusion in 1899 based on anteroposterior relationship of the jaws with each other as

CLASS ICLASS IICLASS III4

4

CLASS III MALOCCLUSION

Prenormal occlusion or mesioclusionMesial or ventral relationship of maxilla to mandibleThe mesial groove of mandibular first permanent molar articulates anteriorly to the mesiobuccal cusp of maxillary first permanent molarHandbook of orthodontics by Robert Moyers; 4th edition

Introduction5

Class III small proportion of all, about 5% of all , more in Asian population Class III wen the mesiobuccal cusp of maxillary first molar occludes interdental space between the distal aspect of distal cusps of mandi 1st molar and mesial aspect of mesial cusps of mandi 2nd molar

5

1.True or skeletal class III mandibular hypertrophyMarked shortening of midface combination

Handbook of orthodontics by Robert Moyers; 4th edition6A] Angle classified CLASSIFICATION

2. Pseudo or functional or postural class III Occlusal prematuritiesPremature loss of deciduous posteriorsEnlarged adenoids3. Class III , SubdivisionClass III on one side and class I on other

Handbook of orthodontics by Robert Moyers; 4th edition7Classification

Molar and canine relation are often not fully class I ii or iii, but rather intermediate relationshipsTherefore, molar and canine that fall between class I and ii are end to end malocclusions Between class I and class iii are super I malocclusions(notation SI)7

B] Deweys modification of Class III

TYPE 1TYPE 2TYPE 3

8Classification

Type 1 arches wen viewed have normal alignment but wen made to occlude show edge to edge relationType 2 mandi incisors are crowded and in lingual relation to maxi incisorsType 3 maxillary incisors are crowded and are in crossbite in relation to mandi incisors8

C] Tweeds divided into 2 categories

ClassificationTextbook of orthodontics by Dr. Samir Bishara9

D] Moyers classification [According to the cause]Osseous (Skeletal)Muscular Dental ClassificationTextbook of orthodontics by Dr. Samir Bishara10

For neuromuscular or functional occlusion Moyer emphasized the need to determine whether it is in centric relation or convenient anterior positionAnterior positioning results from tooth contacts which force mandi in forward positionIn contrast CR is determined by muscles, ligaments, TMJ anatomy under the CNS10

Variants of Skeletal Class IIIFrom Ngan P et al (AJODO 1996;109:38-49)11ClassificationTextbook of orthodontics by Dr. Samir Bishara

A. Mandi Prognathism b.Maxillary retrusion c.Both normal d.Retrusion and protrusion11

Caucasians 1% to 4%Africans-Americans 5% to 8%Asians Japanese 4% to 13%Chinese 4% to 14% Indians 4.1%Textbook of orthodontics by Dr. Samir Bishara12FREQUENCY(Oommen Nainan et al, J Ind Orthod Soc 2013;47(4):328-34)

Higher in asians coz large number of patients show maxillary deficiency12

ETIOLOGY HEREDITY McGuigan described most well known example of genetic influence, the Hapsburg family, having distinct characteristics of prognathic lower jaw

ENVIRONMENTAL INFLUENCESRakosi and Schilli suggested role of habits and mouth breathing (J.Oral Surg 1981;39:860-70)

13

Textbook of orthodontics by Dr. Samir Bishara

13

( Hindawi Publishing Corporation vol 2014 )14According to ARIEL et al

14

CLINICAL FEATURESA] Extraoral features :Concave profile Anterior facial divergenceRetrusive nasomaxillary area Prominent lower third of face/chinSteep mandibular plane angle

15

The Asian patients with Class III malocclusion typically had a more retrusive facial profile and a longer lower anterior facial height. A backward rotation of the mandible was often observed to accommodate the relatively smaller maxilla.15

B] Intraoral features :Class III molar and canine relationshipNarrow upper archDecreased or reverse overjetCrowding in upper arch and spaced lower arch16

Severe class iii are often associated with either anterior or posterior crossbites becoz either maxilla is placed too far back or mandible is too far forwardPresence of occlusal pre maturities resulting in habitual forward positioning of the mandible

16

DIAGNOSIS

Case historyPhotographsStudy modelsRadiographsCephalometric analysis17Textbook of orthodontics by Dr. Samir Bishara

Diagnosis is study and interpretation of data concerning a clinical problem in order to determine the presence or absence of abnormality.The primary goal of these parameters is to help clinician distinguish between a case that requires limited ortho tt vs one that requires comprehensive ortho tt17

1. Photographs 18Extraoral

Intraoral

Diagnosis

Extraoral frontal view at rest, frontal view smiling, profile view at rest to asses pt profile, facial asymmetries and smile lineIntraoral frontal view, right and left lateral view and maxi and mandi occlusal view to provide general overview of malocclusion, gingival condition, and hypoplastic teeth18

Profile Assessment :1. Facial proportions- Straight, convex or concave - Maxillary deficiency showsconcave profile, flattening of infraorbital rim 19

a. Pts with maxillary deficiency usually have a concave profile, evidenced by flattening of the infraorbital rim and area adjacent to nose19

2. Chin position- Chin should not be positioned anterior to a vertical line extending down from soft tissue glabella- Facial convexity decrease with age 20

By blocking upper and lower lip, Evaluate chin position with reference to nose, upper face, and foreheadA degree of chin prominence that wud be normal for adult may suggest a class III skeletal profile in a young child

20

3. Mid-face position - an imaginary line extending from inferiorborder of the orbit through the alar base ofnose and down the corner of mouth- A straight or concave tissue contour indicates midface deficiency21

Evaluate midface by blocking out lower lip and chinThere should be a convexity to imaginary line normally21

4. Vertical proportionsChecked in CO and CRNormal ratio for lower facial height to total facial height is 0.55Decreased in patients with functional shift and overclosure of mandible

22

2. Study models

23Diagnosis

To asses angles classification of molar and canines, overjet and overbite, the approx. amount of crowding or spacing in a dental arch, presence of anterior or posterior crossbiteBcoz model are 3 dimensional representation of pts dentition, they may b used to demonstrate malocclusion to both parent and patient23

3. Radiographs

24

Pantomogram (OPG) Lateral cephalogram Diagnosis

PANTOMOGRAPH-To assess the stage of dental eruption, missing supernumerary or impacted teeth, ectopically erupting teeth, and pathologic conditionLATERAL CEPHALOMETRIC- 1.to evaluate the relationship of the jaws and teeth,2. diagnosis, tt planning, pretreatment, tt process and tt result and stability 24

4. Cephalometric analysisThe SNA angle is significantly lower Negative ANB angle Greater mandibular protrusion Increased gonial angle (more obtuse)Steep mandibular plane angleIncreased lower facial height25Diagnosis

25

Beta angle more than 35 degreeW angle Smaller Articular angle Greater saddle angle 26Diagnosis

26

27 Shendre Shrikant et al conducted a cephalometric study to study anteroposterior relationship of jaws and dental arches in Class I, Class II, and Class III malocclusion (Int J Contemporary Dentistry March 2011;2(2))Diagnosis

Lateral cephalograms and study models of 276 untreated adult orthodontic patients representing Angles Class I, Angles Class II and Angles Class III malocclusions were taken. ANB angle and Wits appraisal were measured on the radiographs which were indicative of the skeletal relationship.ANB ANGLE -The measured values in group I and group II indicated a Class II skeletal base. In group III the mean value showed a Class III skeletal base. However, the increase of ANB angle in group II was more than in group IWITS APPRAISAL -In group I, mean value of Wits appraisal showed a mild Class II skeletal base. Group II showed a moderate to severe Class II skeletal base. In group III the mean value of Wits appraisal showed a Class III skeletal baseWits appraisal decreases as ANB angle decreased 27

28 Hyung-Jun Choi conducted a cephalometric study to compare between characterstics of Class III malocclusion in Korean children with deciduous dentition. (Angle Orthod. 2010;80:8690)He concluded that The relative sagittal position of the maxilla and mandible (ANB difference, facial convexity, Wits appraisal) showed highly signicant differencesThe mandibular length is greater in class III children with maxillary length showing no such difference Diagnosis

28

29 The saddle angle and ramus height are greater while articular angle is smaller for Class IIIThe maxillary incisors show proclination and mandibular incisors show retroclination Large interincisal angle Greater soft tissue convexityDiagnosis

Soft tissue convexity (G-Sn-Pog) was signicantly greater in the normal occlusion group.While the lower lip position (lower lip to E-plane) was similar, there was a signicant difference in the upper lip position (upper lip to E-plane)29

30 Kwong and Lin conducted a cephalometric study comparing characteristics of patients with Class I, Pseudo Class III, and skeletal Class III malocclusion (Clin Dent, 1987 7(2):69-78)Diagnosis

Pseudo Class III malocclusion is an intermediate form between Class I and skeletal Class III malocclusion. The only exception was the gonial angle, which was generally more obtuse in the skeletal Class III sample.Measurement of the gonial angle in the pseudo Class III sample was rather similar to the Class I sample, making this measurement a key diagnostic feature in the differential diagnosis30

31Textbook of orthodontics by Dr. Samir BisharaDiagnosis

ANB angle is negative with smaller than normal SNA or greater than normal SNBAlso wits appraisal can be used Pseudo class III KEY DIAGNOSTIC FEATURE IS GONIAL ANGLE FOR DIFFERENTIATING 31

DIFFERENTIATING A DENTAL CROSSBITE FROM A SKELETAL CROSSBITE32DENTAL ASSESMENT(Molar relationship and overjet)

Class III molar relationshipPositive overjet or end-to-end incisal relationship with retroclined mandibular incisorsClass III molar relationshipNegative OverjetFUNCTIONAL ASSESMENTCompensated Class III malocclusionPseudo Class III malocclusionTrue Class III malocclusionCR-CO ShiftNo CR-CO ShiftTextbook of orthodontics by Dr. Samir BisharaDiagnosis

32

CLASS III SKELETAL GROWTH PATTERNS1. Cranial base (Battagel, EJO 1993)Decreased linear and angular measurements Middle cranial fossa shows posterior and superior alignmentRetrusive nasomaxillary complexForward rotation of mandible 33Textbook of orthodontics by Dr. Samir BisharaDiagnosis

33

2. Maxilla Decreased horizontal growthHorizontal movement of A-point is approximately 0.4 mm/yr (1 mm/yr in Class I patients)3. Mandible Increased mandibular length Shorter ascending ramus with steep mandibular plane angle Obtuse gonial angle 34Textbook of orthodontics by Dr. Samir BisharaDiagnosis

The mandibular articulation is more anteriorly posi- tioned, resulting in a more prominent lower lawThe mandibular prominence along with the decreased length of the maxillary complex may accentuate the typical straight to concave profile in these cases. Typically, patients with Class III malocclusions display dentoalveolar compensation in the form of proclination of the maxillary incisors accompanied with retroclination of the mandibular incisors.

34

4. Growth incrementsSugawara and Mitani said Class III skeletal pattern was established at a young age and does not change fundamentallyTotal increase in posterior cranial base is less in patients with prognathic mandibleAlso, different growth changes in males and females Females patients show more prominent mandible and an increased proclination of maxillary incisors

35Textbook of orthodontics by Dr. Samir Bishara

Similar mandibular growth increments between Class III and Class I patients during prepubertal, pubertal and postpubertal growth periods Battagel41 found that the largest increment of facial growth for males occurred between the ages of 14 and 16 years, whereas in female patients the maximum increment of facial growth occurred between the ages of 9.5 to 12 years, although active growth continued in the nasal area and both jaws after the age of 15 years35

Rabie and Yan Gu (AJODO 2000) identified the diagnostic criteria for PseudoClass III malocclusion and compared it with Class I malocclusion in the southern Chinese population

36PSEUDO CLASS III MALOCCLUSION

CLINICAL FEATURES:Majority showed no family historyClass I molar and canine relationships at HO and Class II or end to end relationship at CRDecreased midface lengthForward position of the mandible with normal mandibular lengthRetroclined upper incisors and normal lower incisors37

TREATMENT OF PSEUDO CLASS IIIRemoval of CO-CR discrepancy avoid normal wear and traumatic occlusal forces to affect the teethRemoves potential adverse effects on growth of jawsEstablishes good functional occlusalImproves facial aesthetics38

Patients with pseudo Class III malocclusion often present with anterior crossbites that are caused by a premature tooth contact or improper positioning of themaxillary and mandibular incisors and the temporomandibular joint.Reverse stainless steel crowns were also used earlier38

Correction of anterior crossbite :

39

Tongue bladeAnterior inclined planeZ-springTreatment

Reverse stainless steel crowns were also used earlier but were unaesthetic

39

Correction of posterior crossbite:40

Removable expansion plateFixed expansion applianceTreatment

40

Correction of occlusal prematurities :41Occlusal splint

Treatment

41

TREATMENT OF TRUE CLASS III Why should the treatment be started early ? (By Renato et al, J Appl Oral Sci 2015;23(1):101-9)Facilitates the eruption of canines and premolars in a normal relationEliminates the traumatic occlusion of incisorsProvides an adequate maxillary growthImproves the self esteem of the child

42

of incisors, which might lead to gingival recession42

43Textbook of orthodontics by Dr. Samir BisharaTreatment

(2) improving skeletal discrepancies and providing a more favorable environment for future growth; (4) simplifying phase II comprehensive treatment and minimizing the need for orthognathic surgery43

44According to Turpin et al (1981)

EARLY TREATMENT TREATMENT DELAYEDTextbook of orthodontics by Dr. Samir BisharaTreatment

The author recommends that early treatment should be considered - positive column.negative column - treatment can be delayed until growth is completed. Patients should be aware of the fact that surgery may be necessary at a later date, even when an initial phase of treatment may be successful.

44

45Orthopedic / myofunctional appliances Orthognathic surgery Orthodontic treatment as needed Treatment

45

Indications :Mild to moderate skeletal discrepancies Growing patients Preliminary treatment before major fixed appliance therapyDecreased lower facial heightPost treatment retention 46MYOFUNCTIONAL APPLIANCES Treatment*Dentofacial orthopaedics with functional appliances by Graber and Petrovic

Take advantage of natural forces and transmit them to skeletal areas to produce desired changeForce is functional and intermittent in nature46

Treatment principles :1. Force applicationCompressive stress and strain act on the structures involved resulting in primary alteration in form with secondary adaptation in function2. Force elimination Elimination of abnormal or restrictive environmental influences on dentitionTeeth respond to reduced force by setting up new balance

47Treatment*Dentofacial orthopaedics with functional appliances by Graber and Petrovic

. Force applicationComplementary muscular or mechanical force application of muscular or mechanical origin2. Force elimination Elimination of abnormal or restrictive environmental influences on dentitionTeeth respond to reduced force by setting up new balance

47

1. REVERSE ACTIVATOR

48

Treatment*Removable orthodontic appliances by Graber and Neuman: 2nd Edition

Unlike activator for class II, in class III activator the restraining effect is directed toward the mandible instead of maxilla.Construction bite is taken in most retruded hinge axis positionAddition Mandibular labial bow added to guide incisors distallyMaxillary labial bow kept at some distance frm incisors to relieve lip pressure48

2. BIONATOR49

*Removable orthodontic appliances by Graber and Neuman: 2nd EditionTreatment

Mandi plate and the two lateral maxi parts extending from 1st premolars to 1st premolars joined together opening the bite just enough to allow labial movement of maxi anteriors just past mandi anteriors.Bite opening is not more than 2mm between the incisal edges1mm thickness of acrylic is removed from behind the mandi anteriors49

3. REVERSE TWIN BLOCK50

Treatment

50

4. FRANKEL III REGULATOR (FR III)More successful in patients with functional shift on closureIncreased overbite of 4-5 mm Early mixed dentitionAlso, as a retentive device after maxillary protraction51

Textbook of orthodontics by Dr. Samir BisharaTreatment

functional appliance designed to counteract the muscle forces acting on the maxillary complex. According to Franke1, the vestibular shields in the depths of the sulcus are placed away from the alveolar buccal plates of the maxilla to stretch the periosteum and allow for forward development of the maxilla.The shields are fitted closely to the alveolar process of the mandible to hold or redirect growth posteriorly. The effectiveness of each appliance is dependent on patient cooperation and wearing them full time. 51

52FRANKEL III

52

1. FACE MASKUsed in patients with mild to moderate Class III with maxillary retrusion2 pads connecting soft tissue in forehead and chin region53ORTHOPAEDIC APPLIANCES

TreatmentTextbook of orthodontics by Dr. Samir Bishara

53

Design and construction :2 pads connecting soft tissues in forehead and chin region with a metallic frameworkElastics attached near the maxillary canine region with a downward and forward pull of 300 to the occlusal planeMetallic banded or acrylic bonded palatal expansion plate can be attached

54

TreatmentTextbook of orthodontics by Dr. Samir Bishara

Adjustable wire with hooks connected to midline framework for protraction using ELASTICS The design of anchorage system for maxillary protraction varies from palatal arches to rapid maxillary expansion (RME)54

Force magnitude and direction:Orthopedic force of 300-600 g/side10-12 hours/dayForce directed 5mm above the palatal plane 30 to 450 protraction force applied at maxillary canine regionTreatment timing:Primary or early mixed dentition periodMostly at the time of initial eruption of maxillary centralsDuration may vary from 3-16 months

55

TreatmentTextbook of orthodontics by Dr. Samir Bishara

Most of the orthopedic changes are observed within the first 3 to 6 months after maxillary expansion.Prolonged use of protraction force results in dentoalveolar changes including mesial movement of maxillary molars and proclination of maxillary incisors.Maxillary protraction below the center of resistance produces anticlockwise rotation of the maxilla. COR distal to maxillary first molar halfway between functional occlusal plane and lower border of orbit55

FACE MASK56

Treatment

56

57A study by Renato et al (J Appl Oral Sci 2015;23(1):101-9)Rapid maxillary expansion followed by facemask therapy was performed, to correct the anteroposterior relationship and improve the facial profile in a 7.6 year old patientTreatment

A 7.6-year old boy presented with Class III malocclusion associated with anterior crossbite; the mandible was shifted to the right and the maxilla had a transversal deficiency. The patient was followed for a 15-year period, after completion of the treatment, and stability was observed57

58

The facemask was used 20 hours a day, for 10 months, after which the patient was requested to use it only at night, and use the acrylic appliance with a palatine grid 24 hours a day. Six months later, a satisfactory relationship in the anteroposterior plane and a mild improvement in the vertical one were observed.58

2. CHIN CUPUsed in skeletal Class III malocclusion with a relative normal maxilla and a moderately protrusive mandible

Two types:Occipital pullVertical pull59

Textbook of orthodontics by Dr. Samir BisharaTreatment

Provide growth inhibition or redirection and posterior positioning of mandibleOccipital pull for patients with mandibular protrusionVertical pull for pts with steep mandi plane angle and excessive lower facial height59

Effects on growth:A) MandibleRedirection of mandibular growth verticallyBackward repositioning or rotation Remodeling with closure of gonial angle Posterior movement of Point B and PogonionA study by Graber showed that the use of a chincup promoted a backward movement of Point B, due to a clockwise rotation of the mandible. (AJO 1977)B) MaxillaPrevents retardation of Anteroposterior maxillary growth

60Textbook of orthodontics by Dr. Samir BisharaTreatment

Graber study Also The length of the mandible also decreased about 1 mm due to the pressure transmitted by the chincup to the condyle, which generated, on the other hand, a delay in vertical growth60

Force magnitude and direction:Orthopedic force of 300-500 g per side14 hours/dayDirected usually through condyle or below the condyle Treatment timing:Primary or early mixed dentitionTreatment time varies from 1 year to 4 year depending on severity61Textbook of orthodontics by Dr. Samir BisharaTreatment

61

62CHIN CUP

62

ESCHLER APPLIANCEAlso known as progenic applianceAppliance design : (Marcio et al, J Appl Oral Sci 2011)Retention clasps e.g. Adams clasps for molars, and intermolar auxiliary clasps for deciduous teeth and premolarsAn eschler labial bow, made in 0.9-mm wire, and adapted at the labial surface of the lower incisorsAn occlusal bite-raising appliance in acrylic resin with a thickness of 2 to 3 mm63Treatment

Eschler modified labial bow to improve intermaxillary effectiveness. One part is active, moving the teeth and other is passive, holding the soft tissue of lower lip away and thus enhancing tooth movementIf necessary, springs and an expansion screw can be added 63

64A Case Report By Marcio Rodrigues de ALMEIDA et al(J Appl Oral Sci 2011,19(4):431-9)A 9 year old patient with chief complain of anterior crossbite treatment by chin cup and eschler appliance1st phase interceptive,treated by chin cup and eschler applianceTreatment

AIM - Angle Class III malocclusion, treated according to a two- stage approach (interceptive and corrective), and a long-term follow-up period.Case - presence of this malocclusion in other family members was reported, lack of development of the middle third, forward shift of the mandible, functional Class III malocclusion.a chincup was used only at night to maintain mandibular retrusion, and the eschler appliance, progenic appliance, was used during the day.64

652 years later, 2nd phase Corrective, to correct the increasing midline diastema in permanent dention. Lasted 14 months

Pre-treatment and post treatment cephalometric superimposition tracing

During the development of the occlusion, the patient was concerned about the gradual increase of the diastema between the central incisors. However, this condition was expected, since the growing mandible caused the proclination of the incisors, thereby increasing arch length Approximately 2 years after the interceptive phase, and due to the patients dissatisfaction with the diastema, the second phase of this protocol was initiated with the installation of a fixed appliance Lasted 65

TANDEM APPLIANCEBy Chun et al, 1999Appliance design : (By Leon Klempner, JCO 2011)Intraoral appliance with one fixed and two removable componentsUpper section is fixed Hyrax, Hass or Quad helix with buccal arms soldered for attachment of protraction elasticsLower similar to removable retainer, with posterior occlusal cover- age and buccal headgear tubes embedded in the lower first-molar regions66Treatment

Modified by Klempner in 200366

67TreatmentAdvantages : (By Pravinkumar S Marure, J Ind Orthod Soc 2014)Highly aestheticPatient friendlyEasy maintenance of oral hygiene Treatment can be suspended or restarted according to clinician

67

68A CASE REPORT BY Dr. Pravin Kumar S Marure et al (J Ind Orthod Soc 2014;48(3):198-205) A 9 old year patient with dental Class I and skeletal Class IIITreatment

68

ORTHODONTIC CAMOFLAGE Indications :Skeletal discrepancies not resolved during mixed dentitionMalocclusions recurring during adolescence after treatment in childhood Mild mandibular prognathism and moderate crowding Types :With extractions Without extractions 69TreatmentTextbook of orthodontics by Dr. Samir Bishara

Masking the defect69

Depending on the malocclusion extraction can be done as follows:Two lower premolars or a mandibular incisorAll four premolarsMaxillary 2nd and mandibular 1st premolars Mandibular second molars[By Jiuxiang Lin, Angle Orthodontist 2006;76(2)]

70Textbook of orthodontics by Dr. Samir BisharaTreatment

70

Class III elastics :From upper molar to lower anteriorsCorrects molar relation by moving the molar mesiallyRetraction of lower anteriors71Textbook of orthodontics by Dr. Samir Bishara

71

ORTHOGNATHIC SURGERYIndications :Continued disproportionate sagittal and vertical growthSevere skeletal maxillary retrusion and mandibular prognathism or both Non-growing patientsCleft lip and palateFacial asymmetries

72Treatment

72

Steps involved :Diagnosis Pre-surgical orthodontics (decompensation)Mock surgerySurgery and stabilizationPost-surgical orthodontics73Treatment

73

Mandibular prognathism :1. Mandibular ramus osteotomy (BSSO)2. Mandibular inferior body osteotomy74Textbook of orthodontics by Dr. Samir Bishara

Treatment

74

Maxillary retrusion :Le Fort I osteotomy with maxillary advancement75Textbook of orthodontics by Dr. Samir Bishara

Treatment

Surgical technique- surgical exposure, osteotomy cuts, pterygomaxillary disjunctionMobilization and advancementFixation Bone grafting75

76

SURGICAL CORRECTION OF CLASS III

77A 22 year old patient with skeletal Class III treated by mandibular setback, BSSO by Dr Yatish Joshi et al in MIDSRTreatment

77

FUTURE INNOVATIONS IN TREATMENT OF CLASS III1. Distraction osteogenesis to advance the maxilla78

Textbook of orthodontics by Dr. Samir BisharaTreatment

An incomplete osteotomy placed above the canine and molar roots was performed through a vestibular incision. Pterygomaxillary disjunction and dissection of the nasal floor and septum were not per- formed. Distraction forces were placed on the maxilla by a reverse-pull headgear and an intraoral orthopedic appliance to advance the maxilla 8 to 12 mm. 78

2. Dental onplants to provide absolute maxillary anchorage79

Textbook of orthodontics by Dr. Samir BisharaTreatment

One of the limitations in maxillary protraction with tooth-borne anchorage devices such as expansion appliances and palatal arches is the loss of dental anchorage (i.e., compensatory dental changes), especially with prolonged maxillary protraction. undesirable effects -loss of arch length, forward movement of maxillary molars, and proclination of the maxillary incisors. These dental changes can be minimized or even eliminated with the use of a novel device called maxillary onplants.The onplant comes as a disk, textured and coated with hydroxyapatite on one side and with an internal thread on the other side. The onplant can be placed on the palatal bone. After osseointegration is complete, forces can be applied to the teeth from the onplant palatal anchorage. apart from providing a stationary orthopedic anchorage, this device can be used in patients with multiple missing teeth79

REFERENCESTextbook of orthodontics by Dr. Samir BisharaHandbook of orthodontics by Robert Moyers; 4th editionContemporary orthodontics by William Profitt ; 5th editionDentofacial orthopaedics with functional appliances by Graber and PetrovicRemovable orthodontic appliances by Graber and Neuman; 2nd EditionAriel Reyes et al, Diagnosis and treatment of Pseudo Class III Malocclusion, Hindawi Publishing Corporation vol 2014

80

80

81Oommen Nainan et al, Evaluation of Malocclusion pattern and Dentofacial characterstics in orthodontically referred urban Indians, J Ind Orthod Soc 2013;47(4):328-34Renato et al, Management of class III malocclusion treated with maxillary expansion and facemask therapy: A 15 year follow up, J Appl Oral Sci 2015;23(1):101-9Hyung-Jun Choi et al, Cephalometric Characteristics of Korean Children with Class III Malocclusion in the Deciduous Dentition, Angle Orthod 2010;80:8690Shendre Shrikant et al, Correlation of the Anteroposterior Relationships of the Dental Arch and Jaw-Base in subjects with Class I, Class II and Class III Malocclusions. Int J Contemporary Dentistry, March 2011;2(2)

81

82Pravin Kumar S Marure et al, Effective maxillary protraction with Tandem Traction Bow Appliance, J Ind Ortho Soc 2014;48(3):198-205Leon Klempner, Early Treatment of Skeletal Class III Open Bite with the Tandem Appliance JCO June 2011Marcio Rodrigues de ALMEIDA et al, Early treatment of Class III malocclusion: 10-year clinical follow-up, J Appl Oral Sci 2011;19(4):431-9Paula Vanessa Pedron Oltramari-Navarro et al, Early Treatment Protocol for Skeletal Class III Malocclusion, Brazilian Dental Journal 2013;24(2): 167-173

82

THANK YOU

83