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A man, aged 28 years 9 months, came for an orthodontic consultation for a skeletal Class III malocclusion
(ANB angle, 3 ) with a modest asymmetric Class II and Class III molar relationship, complicated by an anterior
crossbite, a deepbite, and 12 mm of asymmetric maxillary crowding. Despite the severity of the malocclusion
(Discrepancy Index, 37), the patient desired noninvasive camouflage treatment. The 3-Ring diagnosis showed
that treatment without extractions or orthognathic surgery was a viable approach. Arch length analysis indicated
that differential interproximal enamel reduction could resolve the crowding and midline discrepancy, but a
miniscrew in the infrazygomatic crest was needed to retract the right buccal segment. The patient accepted
the complex, staged treatment plan with the understanding that it would require about 3.5 years. Fixed appliance
treatment with passive self-ligating brackets, early light short elastics, bite turbos, interproximal enamel
reduction, and infrazygomatic crest retraction opened the vertical dimension of the occlusion, improved the
ANB angle by 2 , and achieved excellent alignment, as evidenced by a Cast Radiograph Evaluation score of
28 and a Pink and White dental esthetic score of 3. (Am J Orthod Dentofacial Orthop 2016;149:555-66)
A
n Angle classification for malocclusion focuses diagnosis was critical to determine whether a relatively
on the occlusal relationship of the first molars, noninvasive approach was indicated or even possible.
so it can be misleading for many malocclusions.1 Anterior crossbites with a Class III skeletal pattern
Likewise, anterior crossbites may be deceptive, particu- have a layer of complexity that is not readily diagnosed
larly when associated with a prognathic skeletal pattern unless a systematic test is used such as Lin's 3-Ring
and a concave face. This unusual case appears to be a diagnosis method.2,3 A careful application of the
modest problem based on the molar discrepancy, but it Discrepancy Index and the 3-Ring method demonstrated
is a severe malocclusion based on the American Board that conservative treatment was feasible. However,
of Orthodontics Discrepancy Index score of 37, as shown optimal sagittal alignment of the dentition required a
in Supplementary Worksheet 1. Furthermore, the face, stainless steel miniscrew (OrthoBoneScrew; Newton's
anterior crossbite, and ANB angle of 3 are consistent A, Hsinchu, Taiwan) in the right infrazygomatic crest
with a skeletal Class III malocclusion. Despite the severity to retract the right buccal segment.
of the problem, the patient insisted on the most
conservative treatment possible, so a careful differential DIAGNOSIS AND ETIOLOGY
A man, aged 28 years 9 months, came for an
a
orthodontic consultation with the following chief
Lecturer, Beethoven Orthodontic Center, Hsinchu, Taiwan.
b
Director, Beethoven Orthodontic Center, Hsinchu, Taiwan. concerns: thin upper lip, irregular dentition, and poor
c
Professor emeritus, School of Dentistry, Indiana University; adjunct professor, smile esthetics (Fig 1). There was no contributing
School of Mechanical Engineering, Indiana University and Purdue University at medical or dental history. The clinical examination
Indianapolis, Indianapolis, Ind; visiting professor, Department of Orthodontics,
School of Dentistry, Loma Linda University, Loma Linda, Calif. showed a retrusive upper lip, a deep anterior crossbite
All authors have completed and submitted the ICMJE Form for Disclosure of of all maxillary incisors, a posterior lingual crossbite of
Potential Conflicts of Interest, and none were reported. the maxillary right second premolar, and irregular dental
Address correspondence to: W. Eugene Roberts, Indiana University, School of
Dentistry, 1121 W. Michigan St, Indianapolis, IN 46202; e-mail, werobert@iu. attrition of the maxillary right central incisor. Overbite
edu. was 7 mm, and overjet was 3 mm. There were
Submitted, November 2014; revised and accepted, April 2015. 12 mm of asymmetric crowding in the maxillary arch,
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. and asymmetric Class II (right) and Class III (left) buccal
http://dx.doi.org/10.1016/j.ajodo.2015.04.042 segments associated with a midline deviation of the
555
556 Tseng, Chang, and Roberts
maxilla that was 3 mm to the right (Fig 2). The radio- For the maxillary dentition, the objectives were to
graphic and cephalometric surveys before treatment (1) protract the incisors and retract the molars
are shown (Fig 3). The cephalometric measurements anteroposteriorly, (2) slightly increase the vertical, and
are summarized in Table I. A severely worn facet on (3) slightly increase the intermolar width.
the maxillary right central incisor required coordinated For the mandibular dentition, the objectives were to
orthodontic alignment and restorative care (Fig 4). (1) retract anteroposteriorly; (2) intrude the incisors verti-
cally, and (3) maintain intermolar and intercanine widths.
TREATMENT OBJECTIVES For the facial esthetics, the objectives were to
In the maxilla (all 3 planes), the objective was to (1) increase the upper lip protrusion and (2) increase
maintain the anteroposterior, vertical, and transverse the vertical dimension of the occlusion to achieve an
relationships. orthognathic profile.
In the mandible (all 3 planes), the objectives were
to maintain the anteroposterior and transverse relation- TREATMENT ALTERNATIVES
ships and to rotate the vertical segment clockwise to After a careful evaluation of the patient's problems,
improve the ANB angle. we proposed 3 tentative treatment plans. Treatment
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558 Tseng, Chang, and Roberts
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Fig 5. Bite turbos on the lingual sides of the mandibular canines were used to disarticulate the occlu-
sion (open the bite). Bite turbos for the mandibular incisors were made with a BT Mold (Newton's A) for a
5-mm bite ramp bonder (maxillary). The mold (bonder) is filled with composite resin, positioned against
the lingual surface of the tooth, and then cured with light (mandibular).
Torque U1 U2 U3 L1 L2 L3
High 22 13 11 11 11 13
Standard 15 6 7 3 3 7
Low 2 5 9 11 11 0
Standard upside-down 15 6 7
For the maxillary arch (U1, U2, and U3), the bracket can be placed
upside-down to deliver superlow torque.
U, Maxillary; L, mandibular.
American Journal of Orthodontics and Dentofacial Orthopedics April 2016 Vol 149 Issue 4
560 Tseng, Chang, and Roberts
Fig 7. A, Attachment of Class III early light short elastics (arrow) between the maxillary right first molar
and the mandibular right first premolar (Quail, 3/16 in, 2 oz). B, Attachment of Class III early light short
elastics (arrow) between the maxillary left first molar and the mandibular left first premolar. Note that the
maxillary left central incisor bites on the bite turbo. C, Bite turbos (arrow) bonded at the lingual surfaces
of the mandibular anterior teeth prevent bracket interference while correcting the crossbite.
April 2016 Vol 149 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Tseng, Chang, and Roberts 561
Fig 11. A, At 25 months, space was opened between the maxillary central incisors with an abrasive
strip. B, A tapered diamond bur was used to reduce the mesial surfaces of the maxillary central incisors.
C, The mesial surface of the maxillary right first molar was reduced in a similar manner.
American Journal of Orthodontics and Dentofacial Orthopedics April 2016 Vol 149 Issue 4
562 Tseng, Chang, and Roberts
but pseudo-Class III problems (Class I with anterior average mandibular plane angle and no open bite.
crossbite) are found in approximately 2.31% of children Orthodontic camouflage to treat a Class III malocclusion
9 to 15 years of age. The 3-Ring diagnosis method may result in increased axial inclination of the maxillary
(Fig 17) was developed to help predict the prognosis incisors and decreased axial inclination of the mandibular
for anterior crossbite correction.6 The clinical data incisors, particularly if there is an underlying Class III
showed that 90% of anterior crossbite corrections were skeletal discrepancy.8 If it is necessary to retract the
stable if the following diagnostic criteria were met: mandibular incisors, an axial inclination of at least 88 is
(1) an acceptable facial profile in centric relation; desirable.9
(2) the canines and molars in or near a Class I The Extraction Decision Table of Chang10 (Table III)
relationship; and (3) an evident functional shift. was used to assess the necessity for extractions. The 2
Good candidates for conservative (camouflage) factors favoring extraction were the protrusive profile
treatment have an orthognathic profile (acceptable facial and crowding greater than 7 mm in the maxillary arch.
balance) in centric relation, buccal segments that are However, maxillary extractions would have complicated
approximately Class I, and a functional shift.7 There the correction of the anterior crossbite and might result
were other favorable indicators: a marginally low to in a midface deficiency. Furthermore, the patient was
April 2016 Vol 149 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Tseng, Chang, and Roberts 563
Fig 15. Posttreatment panoramic radiograph, lateral cephalometric radiograph, and cephalometric
tracing, showing the improved profile and the parallel alignment of all tooth roots.
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564 Tseng, Chang, and Roberts
Fig 16. Initial (black) and final (red) cephalometric tracings are superimposed on the anterior cranial
base (left), and on the stable skeletal structures of the maxilla (upper right), and the mandible (lower
right).
strongly opposed to extractions, so the nonextraction torque with the selection of brackets is particularly
option was selected, with the understanding that effective with passive self-ligating brackets15,16
extensive interproximal reduction and infrazygomatic (Table II). Low torque was used on the maxillary incisors
crest anchorage were necessary. to compensate for the side effects of the Class III elastics:
Passive self-ligating brackets with light wires flaring of the maxillary incisors and excessive retraction
facilitate the conservative correction of Class III of the mandibular incisors.17 If low-torque brackets are
malocclusions.7 The bracket is a tube-like appliance insufficient for controlling axial inclinations, bonding
capable of delivering a continuous light force, similar standard-torque brackets upside-down is a viable
to the multiloop edgewise archwire effect.7,11,12 If a alternative.15-17 If a rectangular archwire fails to
patient meets the 3 criteria of the 3-Ring diagnosis, generate adequate root torque, a 20 pretorqued
straight wires and Class III elastics are usually sufficient archwire such as 0.016 3 0.025 in or 0.019 3 0.025
to correct the malocclusion.2 For our patient, Class III in is recommended. Since this patient had standard-
early light short elastics were used initially with bite torque brackets bonded on the mandibular teeth, a
turbos but were then replaced by Class II elastics as 0.016 3 0.025-in nickel-titanium archwire with 20 of
soon as the bite opened and the anterior crossbite was torque was inserted 10 months into treatment to correct
corrected. These are common mechanics for patients the axial inclinations in the anterior segment.17
with an anterior crossbite and Class I buccal segments. This problem could have been prevented by using
If it is necessary to manage an asymmetry or retract higher-torque brackets in the mandibular anterior
the entire mandibular arch, bilateral buccal shelf segment initially (Table II).
OrthoBoneScrews are indicated.7,12,13 Correction of a deepbite can be achieved by molar
Proper torque control with passive self-ligating extrusion, incisor intrusion, or both. This patient's
brackets and light nickel-titanium wires can be chal- deepbite was corrected with anterior bite turbos, which
lenging.14 For this patient, the dental axial inclinations intruded the mandibular incisors and allowed the
were managed with low-torque brackets (Table II), pre- posterior segments to extrude (Fig 16). The advantages
torqued archwires, and temporary skeletal anchorage of anterior bite turbos at the beginning of treatment
devices to retract the right buccal segment. Controlling were to serve as vertical stops for the deep overbite, to
April 2016 Vol 149 Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
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