a fixed reverse labial bow for moderate class iii interceptive treatment. jco 2003

A Fixed Reverse Labial BowA Fixed Reverse Labial Bow
for Moderate Class IIIfor Moderate Class III
InterceptiveInterceptive
TreatmentTreatment
www.indiandentalacademy.com

• The treatment of skeletal Class III malocclusion,The treatment of skeletal Class III malocclusion,
particularly in the late deciduous or early mixedparticularly in the late deciduous or early mixed
dentition, is one of the most challengingdentition, is one of the most challenging
problems confronting the orthodontist.problems confronting the orthodontist.
These patients frequently exhibit anterior orThese patients frequently exhibit anterior or
posterior crossbites, in addition to someposterior crossbites, in addition to some
combination of maxillary skeletal retrusion andcombination of maxillary skeletal retrusion and
mandibular skeletal protrusion.mandibular skeletal protrusion.

• The treatment of this malocclusion raises theThe treatment of this malocclusion raises the
clinical dilemma: Is it better to intervene at anclinical dilemma: Is it better to intervene at an
early age or to wait for craniofacial growth to beearly age or to wait for craniofacial growth to be
fully expressed?fully expressed?

• Because of a lack of success in certain earlyBecause of a lack of success in certain early
treatment cases, some clinicians have nottreatment cases, some clinicians have not
initiated treatment until growth has been fullyinitiated treatment until growth has been fully
expressed. This approach almost always involvesexpressed. This approach almost always involves
a combination of orthognathic surgery anda combination of orthognathic surgery and
orthodontic treatment.orthodontic treatment.

• Early, intervention using such appliances as theEarly, intervention using such appliances as the
chin cup, reverse extraoral traction, or thechin cup, reverse extraoral traction, or the
function regulator (FR-3) of Frankel are usedfunction regulator (FR-3) of Frankel are used
Most cases of minimal to moderate severity areMost cases of minimal to moderate severity are
managed satisfactorily with these approaches,managed satisfactorily with these approaches,
particularly if underlying etiological problemsparticularly if underlying etiological problems
have been resolved.have been resolved.

Face mask therapy followed by RME is the treatment of choice in
Class III cases presenting with maxillary retrusion or Class III
malocclusions presently a combination of retrusion of the maxilla
and protrusion of the mandible. Use of the appliance is restricted
by the extroral nature of the applaince and cannot be used with
poor pateint compliance.www.indiandentalacademy.com

• PATRICK K. TURLEY, D JCO, , VolumePATRICK K. TURLEY, D JCO, , Volume
1988 May(314 - 325): has stated that1988 May(314 - 325): has stated that
• -Compromised results can also be due to poor-Compromised results can also be due to poor
patient cooperation, since orthopedic appliancespatient cooperation, since orthopedic appliances
for Class III treatment can be uncomfortablefor Class III treatment can be uncomfortable
and unesthetic. There are few acceptableand unesthetic. There are few acceptable
alternatives when a patient refuses to wear analternatives when a patient refuses to wear an
extraoral appliance.extraoral appliance.

Recently new arrauy of appliance have been introduced for the
correction of the class III maocculsion
Bio Frankel -3 JCO 2003Modified Tandem applaince JCO 2003

• Although good treatment results have beenAlthough good treatment results have been
achieved with either reverse-pull headgears orachieved with either reverse-pull headgears or
functional appliances,the results can befunctional appliances,the results can be
compromised by poor patient cooperation, sincecompromised by poor patient cooperation, since
such Class III appliances tend to uncomfortablesuch Class III appliances tend to uncomfortable
and unesthetic.and unesthetic.

• Mild to moderate discrepancy present with theMild to moderate discrepancy present with the
treatment outcome is most satisfactory and iftreatment outcome is most satisfactory and if
well retended do not require the any furtherwell retended do not require the any further
orthognathic surgery , for correction. Hence theorthognathic surgery , for correction. Hence the
added importance of increased patientadded importance of increased patient
cooperation during the growing pahse of thecooperation during the growing pahse of the
pateintpateint

This article presents a new approach to theThis article presents a new approach to the
management of mild-to-moderate dental andmanagement of mild-to-moderate dental and
skeletal Class III malocclusions in growingskeletal Class III malocclusions in growing
patients, without relying on special patientpatients, without relying on special patient
cooperation.cooperation.

Appliance DesignAppliance Design
• The SW III consists of an .045" stainless steelThe SW III consists of an .045" stainless steel
archwire that is inserted into the headgear tubesarchwire that is inserted into the headgear tubes
of the upper molar bands . The anterior part ofof the upper molar bands . The anterior part of
the wire restricts the lower incisors duringthe wire restricts the lower incisors during
closure of the mandibleclosure of the mandible

• Each distal end has a clip fabricated from an .Each distal end has a clip fabricated from an .
028" piece of wire, 7mm long, ending in a distal028" piece of wire, 7mm long, ending in a distal
ball end soldered to a 3mm tube (internalball end soldered to a 3mm tube (internal
diameter 1.2mm). The clip prevents the ends ofdiameter 1.2mm). The clip prevents the ends of
the wire from sliding out of the molar tubes.the wire from sliding out of the molar tubes.

• Normally, the patient is instructed to remove theNormally, the patient is instructed to remove the
labial bow for eating, but in especiallylabial bow for eating, but in especially
uncooperative patients it can be ligated to theuncooperative patients it can be ligated to the
molar tubes.molar tubes.
Thus depending upon the degree of cooperationThus depending upon the degree of cooperation
, the removable or the fixed versoin of the, the removable or the fixed versoin of the
Reverse labial bow applaince can be used.Reverse labial bow applaince can be used.

• A variation of this design without the distal clipsA variation of this design without the distal clips
has recently been developed .has recently been developed .
• After measuring the wire in the patient's mouth,After measuring the wire in the patient's mouth,
the clinician adds terminal stops by makingthe clinician adds terminal stops by making
bayonet bends with a birdbeak plier.bayonet bends with a birdbeak plier.

• To ensure the stability of the appliance duringTo ensure the stability of the appliance during
closure, elastics are attached between the distalclosure, elastics are attached between the distal
ends of the wire and the anterior portion of theends of the wire and the anterior portion of the
facebow. This version requires a higher level offacebow. This version requires a higher level of
patient compliance and thus will not be suitablepatient compliance and thus will not be suitable
for all cases.for all cases.

• Restriction of the lower arch and the mandible isRestriction of the lower arch and the mandible is
only one of the orthodontic effects requiredonly one of the orthodontic effects required
during interceptive treatment of moderate Classduring interceptive treatment of moderate Class
III malocclusions.III malocclusions.
• There may be need of correction of varoiusThere may be need of correction of varoius
other factors like , Transerve expansion of theother factors like , Transerve expansion of the
maxilla,{RME} correction of inclination of themaxilla,{RME} correction of inclination of the
upper anteriors.upper anteriors.

• Therefore, this applaine can be used inTherefore, this applaine can be used in
conjunction with one or more other maxillaryconjunction with one or more other maxillary
fixed appliances, such as a rapid palatalfixed appliances, such as a rapid palatal
expander, a palatal arch for incisorexpander, a palatal arch for incisor
advancement , or a tongue crib.advancement , or a tongue crib.

• Case ReportCase Report
• An 8-year-old male presented with an open biteAn 8-year-old male presented with an open bite
and a moderate dental Class III malocclusionand a moderate dental Class III malocclusion
with a skeletal Class III tendency .with a skeletal Class III tendency .

• He was treated with reverse labial bow applianceHe was treated with reverse labial bow appliance
, while the functional interference, while the functional interference
of a tongue-thrust habit was corrected with aof a tongue-thrust habit was corrected with a
soldered tongue crib . He wore the appliancesoldered tongue crib . He wore the appliance
24 hours a day except during meals24 hours a day except during meals

• The malocclusion was corrected in five months.The malocclusion was corrected in five months.
The reverse labial bow was left in place for oneThe reverse labial bow was left in place for one
year to controlmandibular growth, and thereafteryear to controlmandibular growth, and thereafter
was worn only at night for retention.was worn only at night for retention.
• This first phase of treatment produced a goodThis first phase of treatment produced a good
dental Class I occlusion and orthopedic facialdental Class I occlusion and orthopedic facial
balance. The results remained stable two yearsbalance. The results remained stable two years
later.later.

• Stability of results two years after first phase ofStability of results two years after first phase of
treatmenttreatment

DiscussionDiscussion
• The design for the Reverse labial bow applianceThe design for the Reverse labial bow appliance
was first proposed in J CO Volume 1996was first proposed in J CO Volume 1996
Sep(487 - 492): Inverted Labial Bow ApplianceSep(487 - 492): Inverted Labial Bow Appliance
for Class III Treatment FULUNG WANG, Bfor Class III Treatment FULUNG WANG, B

In this case it was advised to take an edge-to-edge construction bite
for mounting the upper and lower casts in the laboratory. There will
usually be 3-5mm of clearance between the upper and lower posterior
teeth .
Construct the removable appliance on the casts from three wire
components :
1. Inverted labial bow (.036" stainless steel)
2. Adams clasps (.028" stainless steel)
3. Finger springs and guide wires (.020" stainless steel)

According to Wang .F the follwing can beAccording to Wang .F the follwing can be
used as criterias for correction of mild toused as criterias for correction of mild to
moderate Class III maloccusion .moderate Class III maloccusion .
• Crossbite only in the incisors—not in the canines orCrossbite only in the incisors—not in the canines or
posterior segmentsposterior segments
• Ability to bite edge-to-edge without difficultyAbility to bite edge-to-edge without difficulty
• Adequate overbiteAdequate overbite
• Mild upper anterior crowdingMild upper anterior crowding
• Uncrowded or spaced lower incisorsUncrowded or spaced lower incisors
• Normal or low mandibular plane angleNormal or low mandibular plane angle
• ANB of –4° or greaterANB of –4° or greater
• Upper incisors tipped linguallyUpper incisors tipped lingually
• Lower incisors upright or labially inclinedLower incisors upright or labially inclinedwww.indiandentalacademy.com

• The objective of interceptive treatment of aThe objective of interceptive treatment of a
moderate Class III malocclusion is to reestablishmoderate Class III malocclusion is to reestablish
incisal guidance and harmonious interdigitation.incisal guidance and harmonious interdigitation.
• Most Class III patients begin to develop anMost Class III patients begin to develop an
initial functional shift of the mandible duringinitial functional shift of the mandible during
childhood.childhood.
• To counteract that tendency during maturation,To counteract that tendency during maturation,
the reverse labial bow applince guides thethe reverse labial bow applince guides the
mandible into a centric relationshipmandible into a centric relationship

• The Frankel III, the bionator III, and theThe Frankel III, the bionator III, and the
modified Hawley appliance for Class IIImodified Hawley appliance for Class III
treatment all have the same effect of inhibitingtreatment all have the same effect of inhibiting
the lower incisors during mandibular closure,the lower incisors during mandibular closure,
but require more patient compliance.but require more patient compliance.

• The SW III is then left in place for retention, usually forThe SW III is then left in place for retention, usually for
no longer than a year. After that, the patientno longer than a year. After that, the patient
• can wear a functional appliance at night, if necessary,can wear a functional appliance at night, if necessary,
until the complete eruption of the permanentuntil the complete eruption of the permanent
• dentition, when the need for further orthodonticdentition, when the need for further orthodontic
treatment or surgery can be evaluated. The Reservetreatment or surgery can be evaluated. The Reserve
Labial bow appliance can be reused as a retainer at theLabial bow appliance can be reused as a retainer at the
conclusion of treatmentconclusion of treatment

Thank youThank you

a fixed reverse labial bow for moderate class iii interceptive treatment. jco 2003

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