Angle (1899) - classified the malocclusions based on occlusal relationships, considering the first permanent molar as the "key"

of occlusion Class III malocclusion is defined in cases that mandibular first molar is positioned mesially relative to the first molar of maxilla

A complicating factor for diagnosis and treatment of Class III malocclusion is its Etiologic Diversity

CONGENITAL ENVIRONMENTAL

HERIDITARY

Cleft lip and palate causing teratogens like Aspirin Dilantin Cigarette smoke 6- mercaptopurine Valium Vitamin D excess premature closure of sutures leading to class iii malocclusion.

Best known examples of genetic influences are the classic HAPSBURG JAW ( Mc Guigan 1966) 1/3rd of a group of children who presented with a severe class III malocclusion had a parent with the same problem and 1/6th had an affected sibling. Litton et al (ajo 1970)

Enlarged tonsils Retained deciduous incisors Difficulty in nasal breathing

premature loss of the sixth-year molar

Environmental factors

Disease of the pituitary gland

a habit of protruding the mandible

Harmonal disturbances

Excessive mandibular growth could arise as a result of abnormal mandibular posture because constant distraction of the mandibular condyle from the fossa may be a growth stimulus- Rakosi & Schilli 1981

Pseudo Class III:

TRUE CLASS III -Mesiocclusion of molars -Class III canine relationship -Anterior crossbite -Possible posterior crossbite -Crowding and /or spacing -Overbite - normal - deep - open ANB=< 0O

Class I with mandibular anterior shift due to premature occlusal contacts

Habitual occlusion

Centric relAtion Kwong & Lin 1987 conducted a cephalometric study class I, pseudo class III and class III malocclusions. Most of the measurements suggest that pseudoclass III is an intermediate form between class I and skeletal class III malocclusions . Only exception was the gonial angle. It was more obtuse in skeletal class III and more or less similar in pseudo class III and classs I malocclusions

Dentoalveolar

Skeletal

mandibular anterior positioning (PROGNATHISM) or growth excess (MACROGNATHIA)

maxillary posterior positioning (RETROGNATHISM) or growth deficiency (MICROGNATHIA),

combination of mandibular and maxillary discrepancies.

DENTAL ASSESSMENT (Molar relationship and overjet)

Class III molar relationship Negative overjet

FUNCTIONAL ASSESSMENT

Class III molar relationship Positive overjet or end end incisal relationship

No CR- CO shift

CR- CO shift

True class III malocclusion

Pseudo class III malocclusion

Compensated class III malocclusion

Ngan Pediatr Dent 19; 386- 395, 1997

PROFILE ASSESSMENT

Evaluate the chin position

Evaluate midface

1. Patients with maxillary deficiency usually have a concave profile, evidenced by a flattening of the infraorbital rim and the area adjacent to the nose 2. By blocking the upper lip and lower lip the chin position is evaluated 3. By blocking out the lower lip and chin , midface is evaluated. There should be a convexity to an imaginary line extending from the inferior border of the orbit through the alar base of the nose, and down to the corner of the mouth. - A straight or concave tissue contour indicates a midface deficiency.

Vertical proportions should be assessed in CO and CR The normal ratio of LFH to TFH is approx 0.55. This ratio is decreased in patients with functional shift and overclosure of the mandible

Cephalometric assessment: To confirm the contributions of the

Maxilla Mandible Maxillary incisors & Mandibular incisors

to the class III skeletal and dental

relationships

Cranial base: More anteriorly positioned articulare when compared to class I Mid cranial fossa posterior and superior alignmentpositions nasomaxillary complex more retrusive relationship Maxilla : Decreased horizontal maxillary growth when compared to class I malocclusion patients Horizontal A point movement
0.4mm/yr in class III patients 1.0mm/yr in class I patients
Battagel EJO 1993

Mandible: Gonial angle more obtuse Short ascending ramus Steeper mandibualr plane angle Mandibular prominence along with decreased length of the maxillary complex accentuate the straight or concave profile
Duration of the Pubertal Peak in Skeletal Class I and Class III Subjects

The growth interval corresponding to the pubertal growth spurt was longer in Class III subjects than in subjects with normal skeletal relationships The larger increases in mandibular length during the pubertal peak reported in the literature for Class III subjects may be related to the longer duration of the pubertal peak. (Angle Orthod 2010;80:5457.)

Early class III treatment

Turpin 1981

Indications

Contraindications

Good facial esthetics Mild skeletal disharmony No familial prognathism Anteroposterior functional shift Symmetrical condylar growth Growing patients with good co-operation

Poor facial esthetics Severe skeletal disharmony familial pattern established No Anteroposterior functional shift assymmetrical condylar growth Poor co-operation

SKELETAL
EARLY TREATMENT

Face mask Chin cup Frankel III appliance Reverse twinblock LATE TREATMENT- SURGICAL or CAMOUFLAGE Mandibular prognathism- ramus osteotomy Maxillary retrognathism- lefort I osteotomy with maxillary advancement

Pseudo class III

Correcting the path of closure

Age : 13yrs 9 months C/O: Dental crowding

Class I molar relation

NORMAL TRANSVERSE INTERARCH RELATIONSHIP MAXILLARY LATERAL INCISOR IN CROSS BITE

HARMONIOUS PROFILE
4MM CROWDING IN THE MAXILLARY AND THE MANDIBULAR ARCHES

PANORAMIC RADIOGRAPH

LATERAL CEPHALOGRAM
Class I skeletal relationship proportional jaws Craniofacial pattern in equilibrium The lower anterior facial height was short mandibular incisors were upright in the basal bone.

treatment plan - to eliminate the dental crowding and establish a good occlusion TREATMENT OPTIONS: 1. EXTRACTION OF FOUR PREMOLARS 2. NON EXTRACTION (expansion of the maxillary arch and buccal tipping of the mandibular
posterior teeth to gain space in both arches)

SECOND OPTION WAS CHOSEN .. REASON: CROWDING WAS MODERATE extractions could make the profile too retrusive

TREATMENT PROGRESS: UPPER ARCH- QUAD HELIX

FOR EXPANSION
LOWER ARCH- LARGER SIZE WIRES WERE USED

After seven months of leveling and alignment

a developing Class III relationship was noted on the right side the right central and lateral incisors in crossbite and slight deviations of the mandibular dental midline and chin to the left.

To correct

this Class III canine relationship, the anterior crossbite, and the midline deviation,

mandibular right first premolar WAS EXTRACTED

The patient and his parents were not concerned about the mild chin deviation, since it did not compromise his facial appearance.

After 25 months of treatment final occlusion showed

Class III molar relation

CLASS I CANINE RELATION

CLASS I MOLAR RELATION

maxillary incisors were tipped labially and the mandibular incisors slightly uprighted and retruded ANB HAS DECREASED FROM 3 TO -0.5 INCREASED MAXILLOMANDIBULAR DIFFERENTIAL TOWARDS CLASS III

CLINICAL EXAMINATION SHOWED CEPHALOMETRIC ANALYSIS SHOW

ANB had decreased to 4.2 MAXILLOMANDIBULAR differential iNCREASED relationship on 5.3 mm TO ANOTHER the left side

Unilateral Class III canine with a negative overjet of 2mm

Due to the severity of the malocclusion, the patient agreed to retreatment

Retreatment Options: 1. surgical-orthodontic correction with maxillary advancement, or

2.

orthodontic treatment involving extraction of the mandibular left first premolar.

Patient opted for the second option Retreatment progress:

Bilateral Class III elastics in place, along with anterior intermaxillary elastic from palatal buttons on maxillary incisors to labial hooks on mandibular incisors.

Retention : Maxillary-Hawley plate and Bonded mandibular 4-to-4 retainer TOTAL TREATMENT TIME WAS 27 MONTHS

RETREATMENT RESULTS

Bilateral Class III Molar and Class I canine relationship Slight maxillary protrusion and mandibular retrusion improving the lip position The occlusal plane was rotated slightly counterclockwise

This patients initial records did not predict this subsequent dental abnormality. He exhibited

a Class I dental relationship, with

no cephalometric indication of a developing Class

IIImalocclusion. The mandibular incisors showed a slight Class III tendency due to their subtle lingual inclination, but such inclinations can also be found in Class II cases.

There was no family history of Class III malocclusion.

7 months into treatment the patient developed a Class III relationship on the right side

In an average male patient of this age, the effective mandibular length (Co-Gn) would be expected to increase twice as much as the effective maxillary length (Co-A)
In this patient, the effective maxillary length increased by 3.9mm during the treatment period, while the effective mandibular length increased by 9.6mm1.8mm more than expected. The Class III relationship on the right side probably appeared as a consequence of this unusual mandibular overgrowth. Still, there were no clinically evident skeletal discrepancies, and treatment was resumed after extraction of the mandibular right first premolar.

A more accentuated mandibular growth tendency continued in the post-treatment years, resulting in a complete Class III malocclusion on the left side. Maxillary protrusion (SNA) decreased by 2.5 and the effective maxillary length remained unchanged, while the effective mandibular length increased by 5.3mm . This pattern produced a reduction in ANB and more of an increase in the maxillomandibular differential than would be expected in the patients age group. Therefore, it seems likely that the late Class III malocclusion was caused by an absence of maxillary growth in combination with an overgrowth of the mandible.

A more unusual aspect of this case is the asymmetrical manifestation of the Class III malocclusion, with an interval of several years between the right and left sides. Unusual mandibular growth could be precipitated by condylar hyperplasia during or after orthodontic treatment However in this patient no common indications of hyperplasia, including
severe facial asymmetry, excessive condylar neck length and/or head width, TMJ complaints,

open bite on the affected side,

a history of facial or mandibular trauma or injury, and hereditary or hormonal disturbances such as acromegaly

were found

After the unilateral Class III relationship developed on the right side,
the case should have been handled as a Class III malocclusion, with follow-up visits scheduled every three months to monitor

mandibular growth

A chin cup or a functional appliance could have been prescribed until the end of the growth period.

Although relapse of Class II or Class III malocclusion is not uncommon, more active retention in this case might have reduced the Class III tendency or at least prompted early retreatment, when the discrepancy would have been more amenable to conservative orthodontics.

Careful observance of occlusal features suggesting a latent Class III tendency may help the clinician anticipate a delayed manifestation, either during or after treatment. Special attention should be given to patients exhibiting signs of such late growth, with active retention used to prevent relapse and follow-up visits scheduled every three months to monitor the patients growth and occlusal relationship.