Tis power point explains eaely correction of class III WITH A NUMBER OF CASE PRESENTATION

1. Early orthopedic correction of
Class III by simultaneous use of
chin cup and intraoral appliances
DR. MAHER FOUDA

2. Vertical pull chin cup

3. Occipital pull chin cup
Chin cup appliance treatment is indicated in
young growing patients with mandibular
prognathism.There is some evidence that a chin cup is more
effective in young children under age 7 than the
same treatment used later .

5. The patients and parents should be
advised of the possibility of
surgical correction at the onset of
interceptive treatment.
A) Cephalogram of a patient at age 8.5
with a WITS of -9 mm. B) Cephalogram
of the patient at age 9.5 after Phase I
with RPE and Class III traction—WITS
reduced to -6 mm. C) Cephalogram of
the patient at age 15.5; unfavorable
WITS change (-6 to -12 mm) during
pubertal growth spurt delayed Phase II
treatment until growth was complete in
order to combine orthodontic
treatment with jaw surgery. D)
Cephalogram of the patient’s father
illustrating a clear genetic component
to strong skeletal Class III growth
pattern—his WITS measures -13.5 mm

6. The wise clinician never makes
guarantees regarding the treatment of
Class III malocclusion because the
outcome of any individual Class III
patients is very difficult to estimate.

7. Graber, Sakamoto, and Sugawara and
co-workers advocate the treatment of
Class III malocclusion as early as is
practical .

8. Unfortunately, despite efforts to modify
excessive mandibular growth, many of
these children ultimately need surgery,
and the chin cup treatment is
essentially transient camouflage. For
that reason, it has limited application .
11-1-2012 13-11-2018
After growth modification

9. There are insufficient data in several
studies to make clear
recommendations regarding the
efficacy of chincup therapy in
retardation of mandibular growth.

10. Long-term use of chin cup with
aggressive protocol will
significantly improve the growth
of mandible in mandibular
prognathism.
Developing Class III malocclusions:
challenges and solutions
Clinical, Cosmetic and Investigational
Dentistry 2018:10

11. 20-1-2016
Age 6 years and 4 months
CASE 1
occipital pull chin cup is used for moderate
orthopedic class III problems for the age group
between 4 and 9 years.

12. 29-8-2017
CASE 1
The theory of using chin cup is that it provides
the direct orthopedic forces to improve
mandibular shape in class III malocclusion .

13. In slow expansion technique, a
patient is ordered to turn the screw
4 times which amounts of 1mm per
week.

14. 11-11-2018
For using chin cup, 4 to 14 years of age is
recommended. Habitually females mature formerly
than males, so patients' gender also influences the
use of chin cup. Level of force should increase
progressively.

15. 11-11-2018CASE 1
Effect of
growth
modification
20-1-2016
Force at the center of chin with the chin cup
is recommended 150 g up to 1200 g.

16. Most of the reported studies
recommended an orthopedic force of
300 to 500 g per side. Patients are
instructed to wear the appliance 14
hours per day.

17. Moreover, 8 to 18 hours per day
is the suggested hours for
wearing this orthopedic
appliance.
I actually do not exceed chin cup force more
than 450 grams on each side to avoid TMJ

18. The orthopedic force is usually
directed either through the condyle or
below the condyle.

19. Early intervention
1. Reduces the skeletal discrepancy and
provides normal growth.

20. Early intervention
2. Achieves as much relative maxillary
advancement as possible.

21. Early intervention
3. Improves occlusal relationship.

22. 4-mproves facial esthetics for more
psychosocial development.
Early intervention

23. Early intervention
5. Reduces or simplifies, phase II or surgical
treatment.
Severe class
III due to
mandibular
protrusion
did not
respond to
growth
modification
.

24. According to ANGLE , in class III ;the
lower permanent molar is ahead of
the upper first molar by a distance of
the width of a premolar or half the
width of a molar ..

25. positive factors that aid in interruption of a
developing class III malocclusion :
1. Good facial esthetics

26. positive factors that aid in interruption of a
developing class III malocclusion :
2. Mild skeletal disharmony
Severe skeletal disharmony

27. positive factors that aid in interruption of a
developing class III malocclusion :
3. No familial prognathism
Mother having
mandibular
prognathism
Daughter having the
same skeletal problem

28. positive factors that aid in interruption of a
developing class III malocclusion :
4. Antero posterior functional shift

29. positive factors that aid in interruption of a
developing class III malocclusion :
5-Convergent facial type
Divergent face

30. positive factors that aid in interruption of a
developing class III malocclusion :
6. Symmetric condylar growth

31. 7. Growing patients with expected good
cooperation.
positive factors that aid in
interruption of a developing class III
malocclusion :

32. Dental assessment
Functional assessment
Profile assessment
Cephalometric assessment
Patient examination needs :

33. Diagnostic criteria for pseudo class III
malocclusion:
Majority showed no family history.
Class I molar and canine relationships at
habitual occlusion( HO) and Class II or end
to end relationship at centric relation( CR).
Dental assessment:

34. Functional assessment:
Generally, a forward functional shift exists on the
lower jaw from the first contact between teeth
which are in crossbite up to where the teeth close
together completely. This forward shift
contributes to the lengthening of the lower jaw
which already tends to be too long.

35. In a normal profile view, the most striking
feature is lower jaw which is far retrusive than the
face above. The general tendency seems to be for
the mandible to grow from the more retruded to a
less retruded position and this is usually true
regardless of the individual facial type.
D. H. Enlow and M. Hans, Handbook of Facial Growth, WB
Saunders, Philadelphia, Pa, USA, 2nd edition, 2008.

36. The maxilla tends to be positioned in a forward
direction much more slowly than does the
mandible, resulting in a decrease in the convexity
of the facial profile .This differential growth in an
anterior direction determines the final facial type
at the completion of growth.
In a profile view,

37. PROFILE ASSESSMENT :
Assess facial proportions, chin position,
mid face position and vertical proportion •
Check vertical proportion in CR and CO •

38. The profile of the patient should be evaluated
in NHP using a line down from the bridge of
the nose to the base of the upper lip and a
second one extending from that point
downward to the chin.
A straight or concave profile in young patients
indicates a skeletal Class III jaw relationship

39. The normal vertical proportion ratio of
lower face to total face height is 55% •
Reduced in patients with functional shift
and overclosure.

40. Differential diagnosis of pseudo- and skeletal
Class III malocclusion
Pseudo class III
Skeletal class III

41. Pseudo class IIIskeletal class III

42. Straight orthognathic profile Concave prognathic profile

44. Early signs of true progressive
mandibular prognathism can be
observed from infancy:
• Straight or concave facial profile
• Malar deficiency • Increased lower
anterior facial height • Anatomically
large lower lip length.

45. In evaluating the Class III relationship
during the primary or mixed dentition
period, it is important to consider
whether the problem is dentoalveolar or
skeletal in origin.
Skeletal class III

46. CEPHALOMETRIC ASESSMENT
The following distinctions can be made in
categorizing the class III sagittal
relationship:1- Class III with dentoalveolar
malrelationship. 2- Class III with a long
mandibular base. 3- Class III with an
underdeveloped maxilla. 4- Class III with
combination of underdeveloped maxilla and
prominent mandible; horizontal or vertical
growth pattern. 5- Class III with tooth
guidance or pseudo-forced bite.

47. CLASS III WITH DENTOALVEOLAR
MALRELATIONSHIP
No basal sagittal discrepancy.
ANB within normal limits.
Problem primarily concentrated in incisal
relationship, with maxillary incisors tipped
lingually and mandibular incisors tipped labially.

48. Many pseudo Class III cases have a tendency to become full
blown Class III later on during the growth period unless
treated.
Protrusive arch wire was used for correction of pseudo class III in early mixed
dentition

49. CLASS III WITH A LONG MANDIBULAR
BASE :
SNA normal with larger SNB , creating a
negative ANB difference.
More obtuse gonial angle .

50. Maxillary length : Measures distance from
condylion to point A.
Mandibular length : From condylion to
gnathion .
(McNamara analysis)

51. Anteriorly positioned mandible with
larger mandibular length and angle.
CLASS III WITH A LONG MANDIBULAR
BASE :
Condylion (cd) - top of the condylar head -
1. Gnathion (Gn)—the most outward and
everted point on the profile curvature of
the symphysis of the mandible, located
midway between pogonion and menton.

52. CLASS III MALOCCLUSION WITH AN
UNDERDEVELOPED MAXILLA :
SNA smaller than normal with normal SNB ,
creating a negative ANB difference.

53. CLASS III MALOCCLUSION WITH AN
UNDERDEVELOPED MAXILLA:
The effective length of maxilla is shorter.
Subspinale (ss // Downs’ A-point)
- deepest point of the anterior
contour of the upper alveolar arch
-

54. Forward position of the mandible
with normal mandibular length.
Retroclind upper incisors and normal
lower incisors
CLASS III MALOCCLUSION WITH
AN UNDERDEVELOPED MAXILLA :

55. CLASS III WITH COMBINATION OF
UNDERDEVELOPED MAXILLA AND
PROMINENT MANDIBLE
Smaller SNA with shorter maxillary base length.
Larger SNB with longer mandibular base length.

56. Cephalometric assessment
SNA (Steiner analysis)
The normal SNA in the mixed dentition is 80.5
degrees.

57. Cephalometric assessment
SNB (Steiner analysis)
The mean value of SNB in the mixed dentition is
77.5 degrees .

58. ANB
Cephalometric assessment
(Steiner analysis)
The mean value of the ANB in the mixed dentition
is 4 degrees .

59. It is a measure of the
extent to which maxilla &
mandible are related to
each other in antero-
posterior or sagittal plane
Used in cases where
ANB angle is considered
not so reliable due to
factors such as position
of nasion & rotation of
jaws
WITS APPRAISAL
The name Wits is short for Witwatersrand, which
is a University in South Africa.
Jacobsen in 1975

60. In males point BO is ahead of AO by 1 mm
In females point AO & BO coincide
In skeletal class 3 BO is located ahead of
AO ( negative reading) .
WITS APPRAISAL

61. Functional occlusal plane: occlusal surfaces of
the maxillary and mandibular 1st permanent
molars and 1st and second premolars.

62. This plane is formed by bisecting the
anterior incisors and the distal cusps of
the most posterior molars in occlusion.
Downs occlusal plane

63. It has been found in discriminant analysis that “Wits”
appraisal is the most important factor in the decision
making from orthodontic camouflage treatment to
surgical options. A “Wits” appraisal from 0 to −5 mm
may be suggestive of a Class III problem being resolved
by means of orthodontic camouflage treatment with
facemask or chin cup therapy .
Ngan P. Early treatment of Class III malocclusion: is it worth the burden? Am
J Orthod Dentofacial Orthop. 2006;129(4):S82–S85.

64. A “Wits” appraisal between −4 and −12 mm
requires further growth treatment response
vector (GTRV) analysis using serial
cephalometric radiographs before a decision
can be made of whether to camouflage or
wait for comprehensive growth before
surgical treatment.
Ngan P, Hu AM, Fields HW. Treatment of Class III problems begins with differential diagnosis of
anterior crossbites. Pediatr Dent. 1997;19(6):386–395.

65. it is located at the most inferior,
anterior point on the frontal bone
adjacent to frontonasal suture.
Hard tissue points Nasion (N):

66. Position of the Nasion
Considering the nasion point, in many cases it may
deviate from its mid sagital plane due to asymmetry
of the nasal bones.

67. Usually variations cannot be detected in the
radiographs because it results in relative
broadening of the image at the nasion point thus
loosing its clearance.
Position of the Nasion

68. When the image of the anterior part of the suture
is not distinguishable, Hunter suggested taking
the most posterior point on the curve as the
nasion .
Position of the Nasion

69. So cephalometrics has limitations because :
1. It gives a two dimensional view of a three
dimensional object.
2-There can be errors in identification of
landmarks. Thus reliability of cephalometrics
comes down.
3. Errors can be made during tracing procedures.

70. 4. Assumptions: Various things are "assumed" in
cephalometrics. a) Symmetry: The various analysis
done on lateral projections are based on the
assumptions that the patient does not have any
skeletal asymmetry then the results of the analysis
may not be accurate. This can be avoided by
analysis of postero-anterior projections.
So cephalometrics has limitations because :

71. N prep-point A(mm)
The linear distance is measured between
nasion perpendicular and point A .It
determines the antero-posterior orientation of
the maxilla relative to the cranial base. In well-
balanced faces : Mixed dentition = 0 mm.
normal
Class III
McNamara analysis

72. Point Pognion to Nasion Prependicular .It
relates the mandible symphysis to the
cranial base. If point Pognion lies anterior
to Nasion prependicular, the measurement
will be positive.
N prep-point pg(mm) McNamara analysis

73. If point Pognion lies behind to Nasion
prependicular, the measurement will be
negative.
Norm for mixed dentition: -8 to -6 mm
N prep-point pg(mm) McNamara analysis

74. Cephalometrics is not an exact science..
Even though head films can be
measured with precision, the
measurement error can vary
greatly with any given
landmark.
A method of cephalometric evaluation
James A. McNamara, Jr., D.D.S., Ph.D. Ann Arbor. Mich.
Am. J. Drrhod. Dewmher 1984

75. Unfortunately cephalometric
analysis may be potentially
misleading.
Maxillary protraction for early orthopedic
correction of skeletal Class III malocclusion
Paul W. Major DDS, MSc, MRCD(C) H.E. EIBadrawy, MS,
HDD, DDS
Pediatric Dentistry: May/June, 1993 - Volume 15, Number 3

76. Cephalometric analysis may not be
the most reliable tool to
differentiate whether the maxilla or
mandible contributes to the skeletal
disharmony.
Treatment of Class III problems begins with differential diagnosis of
anterior crossbites
Peter Ngan, DMD Annie M. Hu, DDS, MS Henry W. Fields, Jr., DDS,
MS, MSD
American Academy of Pediatric Dentistry
Pediatric Dentistry - 19:6, 1997

77. The ideal patient for chin cup treatment of
excessive mandibular growth has :
1- A mild skeletal problem with the ability to
bring the incisors end to end or nearly so.
2- Short vertical height .
3-Normally positioned or protrusive but not
retrusive lower incisors .

78. 26-7-2016
Age 5
years
and 10
months
CASE 2 Evidence suggests that
treatment of
mandibular protrusion
is more successful when
it is started in the
primary or early mixed
dentition.

79. CASE 2
15-1-2017

80. CASE 2
occipital pull chin cup and lower posterior bite plane
appliances were used.
24-5-2017

81. Lower posterior bite plane removable
appliance was used to disengage the
occlusion and to maintain the vertical
height of the face .

82. CASE 2
19-12-2017

83. 30-10-2018
CASE 2

84. ‫متولى‬ ‫زينه‬ Anterior view
‫الميالد‬ ‫تاريخ‬7-9-2010
1
2
3 4
5
CASE 2
CASE 2

85. 30-10-2018
26-7-2016
Before
Intermediate
CASE 2 Effect of growth modification

86. Growth modification on the mandible, on the
other hand, is not as stable because it is
genetically controlled. Treatment with
appliances such as chin cups often result in
relapse after treatment
Mitani H, Sakamoto T. Chin cap force to a growing mandible. Long-term clinical reports. Angle Orthod 1984
April;54(2):93–122.
VanLaecken R, Martin CA, Dischinger T, Razmus T, Ngan P. Treatment effects of the edgewise Herbst appliance: a
cephalometric and tomographic investigation. Am J Orthod Dentofacial Orthop 2006 November;130(5):582–93.
Patient did not
show up for 2
years after a
period of growth
modification
11-1-2012
13-12-216

87. Owing to its high rate of relapse, treatment
of Class III malocclusion remains
challenging for orthodontists, particularly
in young growing patients.
Systematic review Effect of chin-cup treatment on the temporomandibular joint: a systematic review Monika
A. Zurfluh, Dimitrios Kloukos, Raphael Patcas and Theodore Eliade
European Journal of Orthodontics, 2015, Vol. 37, No.3
11-1-2012
13-12-216
Patient did not
show up for 2
years after a
period of growth
modification

88. 4-1-2016
CASE 3
Age 6 years and 9
months

89. 4-1-2016 CASE 3
Age 6 years and 9 months

90. 11-1 -2017
Occipital pull chin cup and upper inverted labial
bow appliances were used .Patient was seen every
month to check for the removable appliance and
adjust the force of the chin cup to avoid its
displacement to one side .
CASE 3

91. CASE 3
upper
inverted
labial bow

92. 28-3-2017 CASE 3

93. 23-8-2017 CASE 3

94. 30-1-2018 CASE 3

95. 4-1-2016
30-1-2018
CASE 3
Effect of growth
modification

96. When the mandible is excessive
and the maxilla is deficient, a
combination type of chin cup and
facemask would be used.

97. Perhaps 50% of the patients who undergo
any type of early Class III intervention need
an additional phase of early treatment
before the final phase of fixed appliance
therapy. This may mean that chin cup
therapy is resumed or that another phase of
rapid palatal expansion, with or without
facial mask therapy, may be indicated.
26-8-2013 13-8-2017 22-7-2018
Chin cup
plus lower
posterior
bite plane
were
usedFor four years
Face mask

98. 26-8-2013 CASE 4

99. 13-8-2017 CASE 4

100. 23-8-2017 CASE 4

101. 23-8-2017 CASE 4

102. 23-8-2017 CASE 4

103. 22-7-2018 CASE 4

104. 22-7-2018
CASE 4
Effect of growth modification
26-8-2013
23-8-2017

105. CASE 5 initial

106. progress
CASE 5

107. progress
CASE 5

108. 29-1-2018
CASE 5
progress

109. CASE 5
progress

110. CASE 5
progress

111. CASE 5
9-5-2018
3-6-2014
Effect of growth modification

112. Mitani H.Recovery growth of the mandible after chin cup
therapy : fact or fiction.Semin Orthod 2007 ; 13:186 -99 .
•Mitani hypothesized that compressive
force on the condyle ; if released
before growth modification , will lead
to recovery or rebound growth after
chin cup use .
Compressive force

113. Mitani H, Fukazawa H . Effects of chin cup force on the timming and amount of mandibular growth
associated with anterior reversed occlusion( Class III malocclusion ) during puberty .Amer J Orthod
Dentofacial Orthop 1986 December ;(6):454-63 .
Compressive forces on the condyle with
chin cup slow down condylar growth
and may even modify the growth
direction of the mandible .
Compressive forces on the condyle
Mandible is directed
downward and
backward

114. Graber et al contended that because Class III
malocclusions are among the most difficult to treat
and surgical intervention is contemplated in some
cases, it makes good sense to try early treatment
with at least a chin cap to prevent worsening of the
malocclusion.
11-1-2012

115. Some patients with skeletal Class III malocclusions
exhibit unexpected and progressive mandibular growth
and relapse of the anterior crossbite during pubertal
growth, even though the Class III skeletal profile and
occlusion have been previously corrected.
Choi et al., 1999; Tahmina et al., 2000).
11-1-2012 13-11-2018

116. CASE 6
initial

117. progress
CASE 6

118. progress
CASE 6

119. 12-11-2018
progress

120. CASE 6
12-11-2018
15-11-2014
Effect of growth modification

121. 1-Increased gonial angle
DIAGNOSTIC CHARACTERISTICS OF AN
UNFAVOURABLE CLASS III GROWTH

122. DIAGNOSTIC CHARACTERISTICS OF AN
UNFAVOURABLE CLASS III GROWTH
2- antegonial notch

123. 3-Backward direction of condylar growth
Increase in Ant. Face height. May
occur in connection with growth of
cranial base:
DIAGNOSTIC CHARACTERISTICS OF AN
UNFAVOURABLE CLASS III GROWTH

124. Hyperdivergent patient.
4=Thin mandibular symphysis
DIAGNOSTIC CHARACTERISTICS OF AN
UNFAVOURABLE CLASS III GROWTH

125. Mandibular incisors are retroclined as child
becomes older .Theire roots tend to press against
the labial plate producing a WASH BOARD EFFECT.
Maxillary incisors are usually flared anteriorly.
5. Compensation in position of upper and lower
incisors in response to disproportionate jaw
growth:
DIAGNOSTIC CHARACTERISTICS OF AN
UNFAVOURABLE CLASS III GROWTH

126. This is usually seen in lower anterior
teeth. Overenthusiastic aim at
proclining these teeth to reduce overjet
can lead to the so called washboard
effect and resultant bone loss or root
resorption as teeth touch cortical bone
WASH BOARD EFFECT

127. The wise clinician never makes guarantees regarding the
treatment of Class III malocclusion because the outcome of
any individual Class III patients is very difficult to estimate.
Severe class III

128. CASE 7
initial

129. occipital pull CC is used for moderate
orthopedic class III problems for the
age group between 4 and 9 years.
CASE 7

130. Patient was referred to pedodontist to
endodontically treat the deciduous
cuspids to grind them to prevent any
obstruction to movement of the
mandible posteriorly .
CASE 7

131.  THE APPLIANCES USED WERE AN
OCCIPITAL CHIN CUP, PORTER
EXPANDER AND LOWER REMOVABLE
POSTERIOR BITE PLANE APPLIANCE
OCCIPITAL CHIN CUP
PORTER EXPANDER
LOWER REMOVABLE
POSTERIOR BITE PLANE
APPLIANCE
CASE 7

132. CASE 7
After growth modification

133. CASE 7
10-10-2018
15-2-2014
Effect of
growth
modification

134. Case 8
initial

135. Occipital chin cup and inverted
labial bow appliance were used
Posterior
bite plane
Case 8

136. Direction of force
- If the pull directed below the condyle, the force of
the appliance may lead to a downward and
backward rotation of the mandible.
- .
Case 8

137. If no opening of the mandibular plane angle is
desired, the force should be directed through the
condyle to help restrict mandibular growth
Direction of force

138. Case 8
initial

139. 19-3-20171-2-2016
Effect of growth modification
Case 8initial after growth modification