1 Class III camouflage

Camouflage of moderate Class III malocclusions with extraction of lower second molars and mandibular cervical headgear
Diego Rey Mora*, Giovanni Oberti**, Martha Ealo***, Tiziano Baccetti****
* DDS, Professor,Department of Orthodontics, CES University, Medellin, Colombia. ** DDS, Assistant Professor, Department of Orthodontics, CES University, Medellin, Colombia. ** DDS, Orthodontic Resident, Department of Orthodontics, CES University, Medellin, Colombia. **** DDS, PhD, Assistant Professor, Department of Orthodontics, University of Florence, Italy Correspondence to: Tiziano Baccetti University of Florence Via Ponte di mezzo 46-48, 50127 Firenze, Italy Telephone: +39.055.354.265 Fax: +39.055.321.144 E-mail: t.baccetti@odonto.unifi.it

Review of the Literature

Orthodontic camouflage is a viable alternative for the treatment of the mild to moderate skeletal discrepancies of the maxillary structures with the aim of correcting the occlusal relationships in patients who, for different reasons, decide not to be treated surgically.1 An ideal candidate for the camouflage treatment should present little residual growth potential, and mild to moderate crowding in order to be able to use the space of the extractions, thus allowing for the achievement of the orthodontic camouflage and improving the dento-skeletal relationships1. A commonly used treatment in the correction of Class III malocclusion

Orthodontic camouflage in patients with slight or moderate skeletal Class III malocclusions, can be obtained through different treatment alternatives. The purpose of this paper is to present a treatment that has not been described in the literature and which consists of the extraction of lower second molars and distal movement of the posterior segments by means of mandibular cervical headgear (MCH) and fixed appliances as a camouflage alternative. The force applied by the MCH was 250 gr per side (14hr/day). The total treatment time was 1 1/2 years. Conclusion: the extraction of lower second molars along with the use of mandibular cervical headgear is a good treatment alternative for camouflage in moderate Class III patients in order to obtain good occlusal relationships without affecting facial esthetics or producing marked dental compensations.

Rey Mora D, Oberti G, Ealo M, Baccetti T. Camouflage of moderate Class III malocclusions with extraction of lower second molars and mandibular cervical headgear. Prog Orthod 2007;8(2):300-7.

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with maxillary retrusion in young patients is orthopedic maxillary protraction with a face mask. This therapy produces an average maxillary advancement of 1-2 mm2. Ishii et al.3 found that with the combined use of maxillary protraction and chin cup in cases with severe skeletal Class III, the maxilla protracted from 1.5 to 2 mm and point B retruded 2 mm due to a clockwise mandibular rotation. In growing patients with mandibular prognathism, the most commonly used treatment is the chin cup, which positions the mandible posteriorly due to a clockwise mandibular ro-

tation and closure of the gonial angle2. Baccetti et al.4 and Rey et al5 proposed the use of the Mandibular Cervical Headgear (MCH) in growing patients with Class III malocclusions associated with mandibular protrusion. This treatment modality produces a distalization of the lower molars and redirects growth in a vertical direction. Regarding the orthodontic treatment in patients at the completion of growth, different alternatives for the camouflage of the Class III skeletal malocclusion have been presented. Sato6, in 1994, noted the importance of the posterior

In pazienti con malocclusione scheletrica di III Classe lieve o moderata possibile ottenere un camouflage ortodontico mediante un trattamento alternativo. Questo lavoro vuole presentare una proposta terapeutica, non precedentemente descritta in letteratura, che prevede le avulsioni dei secondi molari inferiori e la distalizzazione dei segmenti latero-posteriori attraverso lapplicazione di trazione extraorale cervicale inferiore (TEO) e di apparecchiatura fissa come tecnica alternativa di camouflage. La forza applicata mediante TEO di 250 gr per lato (per 14 h al giorno). La durata complessiva del trattamento di circa un anno e mezzo. Conclusioni: nei casi di lieve malocclusione di III Classe, le avulsioni dei secondi molari inferiori con lutilizzo di una trazione extraorale cervicale inferiore rappresentano una valida proposta alternativa di camouflage che permette di ottenere buoni rapporti occlusali senza interferire sullestetica facciale o provocare notevoli compensazioni dento-alveolari.

Key words: Class III malocclusion; mandibular headgear; orthodontic camouflage.

discrepancy as an etiologic factor of the development of such malocclusion affecting the occlusal plane. This is why he proposed the MEAW Technique (Multi-loop Edgewise Arch-Wire) developed by Kim7 in order to reconstruct the occlusal plane and correct the Class III discrepancy. Another form of camouflage is the use of Class III elastics, thus allowing a compensation by lingualization of the lower incisors and labialization of the upper incisors. However, in more severe cases, certain extractions are necessary as a camouflage method. The most commonly used pattern of extractions is the removal of the lower first premolars or the extraction of the upper or lower second molars, which are used in the correction of not only Class III, but also Class II malocclusions8-11. Authors such as Smith (1958), Trottier (1958), Halderson (1959), Tulley (1959), Rindler (1957), Huggins (1978), Lawlor (1978) and Marceau (1980), have successfully reported the extraction of second molars followed by migration of the third molars in the extraction site11. According to Chipman12, this procedure is indicated in order to facilitate the distal movement of the first molar when existing second molars are very decayed, ectopic, severely rotated, or when mild to moderate deficiency in the arch length exists, with an acceptable facial profile. In Class II malocclusions, the Headgear has been used to distalize the upper first molar, thus

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correcting the molar and/or skeletal sagittal discrepancy13,14. Similarly, in Class III a MCH can be recommended to distalize the lower first molars5. Most of the studies carried out on the extraction of second molars agree that the optimal moment to perform the extraction of the second molar is as soon as they erupt and when the crown of the third molar is complete. Also, radiographically, there must be evidence of root formation which is approximately between 12 and 14 years of age11. In order to perform these extractions according to Lehman10,11 it was taken into account that the path of eruption of the third molar is at 30 with respect to the longitudinal axe of the first molar. The extraction of the second molars can have several advantages, such as: reduction in quantity and duration of the therapy with fixed appliances9; rapid eruption of the third molar8, aiding in the prevention of late incisor crowding9,16; facilitating the distal movement of the first molar and anterior dentition when the overjet has to be corrected9,10; less residual spaces left at the end of the orthodontic treatment9,10; reduction of probability of relapse due to greater stability given the interscupation between the bicuspids9; maintenance of the facial aesthetics9,14; avoiding complications of the surgical removal of impacted third molars9. Little has been reported regarding the extraction of the lower second molar for the camouflage of Class III malocclusions. Lin and Yan Gu15 propose the extraction of the lower permanent second molars in order to treat severe Class III with the TipEdge Technique. In a sample of 13 patients with an average age of 13.2 years and duration of treatment of 2.6 years, they found that the overjet improved 5.5 mm, reaching a positive value, the upper incisors moved labially 2.1, and the lower proclinated 12, passing from 83.8 pretreatment to 71.8 post-treatment, thus achieving a dental compensation and improving the facial profile. There is controversy regarding this treatment, namely the behavior of the third molar, keeping in mind its root formation16, inclination, etc. The literature presents several research articles like the one carried out by Rindler8 in 1977, which evaluated 78 patients between 10 and 15 years of age with extractions of the upper and lower second molars. The results showed that the third molars work adequa-

Le camouflage orthodontique dans les patients prsentants de lgres ou modres malocclusions squelettiques de la classe III, peut tre obtenu par diffrentes solutions de traitement. Le but de cet article est de prsent un traitement qui n'a pas t dcrit dans la littrature et qui comprend l'extraction des deuximes molaires infrieures et du mouvement distal des segments postrieurs au moyen de mandibular cervical headgear (MCH) (MCH) et appareils fixes comme alternative de camouflage. La force applique par le MCH tait 250gr par ct (14hr/day). Tout le temps de traitement tait des 1 1/2 annes. Conclusion: l'extraction des deuximes molaires infrieures avec l'utilisation du mandibular cervical headgear (MCH) est une bonne alternative de traitement pour le camouflage dans les patients qui prsentent une modre classe III pour obtenir de bons rapports occlusals sans faire un compromis sur l'esthtique faciale ou produire des compensations dentaires marquees.
Traduit par Maria Giacinta Paolone

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tely in the place of the extracted second molars. Cavanaugh 17 in 1985, in a sample of 25 patients, extracted the four second molars, at 10 1/2 years of age (young) and 18 1/2 years (adults) and found that the upper, as well as the lower third molars usually erupt in the place previously occupied by the extracted second molars. Gaumond18 reported 11 cases of enucleation of unerupted lower second molars in order to see the behavior of the third molar, and found that 87% erupted in an adequate position similar to that which Gooris19 and Richardson20 found.

Orton-Gibbs21,22 evaluated a sample of 63 patients at the beginning, the end and three years posttreatment with panoramic radiographs and study models, and found that the third molars began to erupt towards mesial and when they reached occlusion, they straightened out vertically without affecting the periodontal health. The purpose of this article is to describe the extraction of lower second molars with the objective of distalizing the lower first molars using a Mandibular Cervical Headgear as a treatment alternative for a moderate skeletal Class III malocclusion.

Clinical case (M.S.)

A female, 13 years old, with a Class III skeletal malocclusion, moderate open bite, edge to edge incisor relationship and, with a straight profile (Fig. 1; Tab. 1). Surgical treatment was suggested due to the skeletal relationship and the advanced stage of growth development (Cervical Stage 5 in cervical vertebral maturation), but it was discarded by the patient for personal reasons. As an alternative correction of the malocclusion, orthodontic treatment was offered, which consisted of: mandibular cervical headgear (MCH) and lower second molar extractions in order to distalize the lower first molars, creating space for occlusal corrections. The MCH protocol dictates that bands are adapted on the first lower permanent molars with soldered buccal tubes; the inner arch of the headgear was adapted with a bayonet stop, leaving the anterior part of the arch in front of the lips without interfering with lip seal. Applied force: 250 grams per side, 14 hours a day; fixed upper and lower appliances with short intermaxillary elastics to facilitate good dental interdigitation; retention: an upper Hawley retainer was installed with a distal arch extension over the occlusal surfaces of the upper second molars in order to avoid their extrusion due to lack of occlusal contact after the lo-

El camuflaje ortodntico en pacientes con maloclusiones leves esquelticas o moderadas clase III, se puede obtener con diferentes tipos de tratamientos. El propsito de este trabajo es el de presentar un tratamiento que no se ha sido descrito aun en literatura; que consiste en la extraccin de segundas molares inferiores y del movimiento distal mediante la aplicacin de una traccin extraoral cervical mandibular (MCH) y de la aplicaciones de aparatologa fija como alternativa del camuflaje. La fuerza que se aplic mediante el MCH fue de 250gr por el lado (14hr/diarias). El tiempo total del tratamiento fue de de 1 1/2 ao. Conclusin: la extraccin de los segundas molares inferiores junto con el uso del de la traccin cervical mandibular es una buen alternativa teraputica para el camuflaje en pacientes clase III moderadas, de esta forma puede obtener una buena relaciones oclusal sin afectar la esttica facial o producir compensaciones dentales marcadas.
Traducido por Santiago Isaza Penco

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Figs 1a-k Initial extraoral and intraoral records with panoramic x-ray and Lateral Cephalograms (13 years of age)

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Figs 2a-k Final extraoral and intraoral records with panoramic x-ray and Lateral Cephalograms (15 years of age).

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Table 1 Cepalometric Measurements. Initial Skeletal Measurements SNA () SNB () ANB () WITS (mm) Co-Pt A (mm) Co-Pg (mm) Max/Mand difference (mm) MPA () ANS to Me (mm) Pt A to Nasion perp (mm) Pg to Nason perp (mm) Fig. 3 Upper retainer with occlusal support in upper second molars. Dental Measurements Overbite (mm) Overjet (mm) Interincisal angle () U1 to Frankfort () L1 to MPA () U1 to Palatal Plane (mm) U6 to Palatal Plane (mm) L1 to MP (mm) L6 to MP (mm) Molar Relationship (mm) Soft Tissue Nasolabial angle () Final

84.3 83.5 0.9 -8.5 90.4 119.8 29.4 24.3 64.6 2.3 3.5

84.5 84.2 0.4 -4.8 90.9 120.4 29.5 22.6 64.6 2.3 4.6

0 0 133.8 116.6 85.4 24 17.1 39.4 25.4 5

1.5 1 131.3 119.3 86.7 24.5 19.6 40.9 24.4 1.5

132

123

wer second molar extraction. The distal extension continues until the eruption of the lower third molars (Fig 3). Total active treatment time was 1 1/ year, followed by the reten2 tion period (Hawley retainer) (Fig. 2, Tab. 1).

Conclusions
The extraction of second molars and the use of Mandibular Headgear allows the achievement of good occlusal relationships in pa-

tients with moderate Class III malocclusions because of the distal movement of the lower teeth. The facial esthetics is not affected since there are no changes due to the compensatory inclination of the anterior teeth, which are common with the extraction of the bicuspids. The third molar takes the place of the second molar with no major complication. Patient cooperation is required in the use of the extra oral traction, and its use is suggested during the three months before the extractions are done.

References
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12. Chipman MB. Second and third molars: their role in orthodontic therapy. Am J Orthod Denthofacial Orthop 1961; 47: 498-520. 13. Graber TM. The role of upper second molar extraction in orthodontic treatment. Am J Orthod Denthofacial Orthop 1955; (41):354 14. Basdra E, Stellzig A, Komposh G. Extraction of maxillary second molars in the treatment of class II malocclusion. Angle orthod 1996; 66(4): 287-292 15. Lin J, Gu Y. Lower second molar extraction in correction of severe skeletal class III malocclusion. Angle Orthod 2006; 76(2): 217-225 16. Richardson M, Millis K. Late lower arch crowding: The effect of second molar extraction. Am J Orthod Denthofacial Orthop 1990 Sep; 242246 17. Cavanaugh JJ. Third Molar changes following second molar extraction. Angle Orthod 1985 Jan; 55(1): 7076. 18. Gaumond G. Second molar germectomy and third molar eruption. 11 cases of lower second molar enucleation. Angle Orthod 1985 Jan; 55(1): 77-88.

19. Gooris CGM, Artun J, Joondeph DR. Eruption of mandibular third molars after second-molar extractions: A radiographic study. Am J Orthod Dentofacial Orthop 1990; 98:161-67. 20. Richardson ME, Richardson A. Lower third molar development subsequent to second molar extraction. Am J Orthod Dentofacial Orthop 1993 Dec;104(6):566-74. 21. Orton-Gibbs S, Crow V, Orton HS. Eruption of third permanent molars after the extraction of second permanent molars. Part 1: assessment of third molar position and size. Am J Orthod Dentofacial Orthop 2001 Mar; 119(3):226-38. 22. Orton-Gibbs S, Orton S, Orton H. Eruption of third permanent molars after the extraction of second permanent molars. Part 2: Functional occlusion and periodontal status. Am J Orthod Dentofacial Orthop 2001 Mar; 119(3):239-44.

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