This document discusses various treatment approaches for Class III malocclusion. It begins by defining Class III malocclusion and describing its prevalence and causes. It then discusses the controversies surrounding the timing of treatment, summarizing that early treatment is generally best when positive growth factors are present. The document evaluates several appliances that can be used for growth modification in younger patients, such as facemasks and chin cups. For older patients, it discusses camouflage orthodontic treatment using techniques like proclining incisors or extractions, as well as temporary anchorage devices. Finally, it briefly outlines orthognathic surgical options including mandibular osteotomies and maxillary procedures.

2. Dr. Nagi Hussein Al-Awdi
MSc. In clinical orthodontic
Class III malocclusion: Accept
the Challenge

3. Introduction

4. Introduction
 Class III malocclusion is considered the most challenging
malocclusion in orthodontic treatment planning faced by
orthodontic clinicians.
 Class III malocclusion remains a controversial issue
among clinicians and researchers.

5.  The prevalence of Angle Class III malocclusion ranges
between 5% to 19%, with the lowest among the Caucasian
populations and the highest among the Asian populations.
 Its prevalence among male
& female:
on gender differences.
prevalence of Angle Class III malocclusions

6. Classification of class
III malocclusion

7. Classification of class III malocclusion
Truly skeletal III
Functional or pseudo
class III

8. Etiology Of Class III Malocclusion
 class III malocclusion may have a multifactorial etiology it
can be broadly classified as:
1. genetic:
 Familial tendency
1/3 of patients with severe class III have a parent with class III
problems.
 Racial:
Class III malocclusion is found commonly in certain races,
- 3% in Caucasians
- 5% African American
- 14% Chinese and Japanese
- 3.4% Indians

9. Aetiology
 class III malocclusion may have a multifactorial etiology it
can be broadly classified as:
 2.Environmental (epigenetic):
- large tongue
- airway problems (adenoids)
- Mouth breathing
 3. Systemic:
Hormonal disturbance as in acromegaly.
 4.Teratogenic:
Teratogenic causing cleft lip and palate like some drugs

10. Dilemmas surrounding
Class III treatment

11. Timing of treatment Type of appliance
A B
Dilemmas surrounding Class III treatment

12. Timing of Treatment for Class III Malocclusion
 The timing of treatment for Class III malocclusion has always
been a matter of debate among orthodontists(controversial).
Should treatment start early in the
patient’s childhood or should clinicians
wait until growth is completed and then
proceed with orthognathic surgery?
 when we start an early phase of orthodontic or orthopedic
treatment; how successful are these treatments long-term?
.
Effectiveness in
the long term
Best time to
start treatment

13. Timing of Treatment for Class III Malocclusion
 Although the ideal timing for skeletal Class III remains
controversial in the literature,
• The timing of early treatment is crucial for a successful
outcome
 pseudo Class III must be intercepted at the earliest time
possible. to eliminate the mechanical interference caused by
the overclosure of the mandible and to avoid some
complications often associated with it such as, lower incisors
gingival recession, excessive incisal wear, increased chances
of temporomandibular joint (TMJ) dysfunction.

14. Timing of Treatment for Class III Malocclusion
• In the literature review, Some studies have reported that
treatment should be carried out in patients less than 10 years
of age to enhance the orthopedic effect.
• The optimal time to intervene in Class III malocclusion seems
to at the time of eruption of the maxillary incisors
• In contrast, other studies have found that patient age had
little influence on treatment response and outcome.
• Hence, there is no strong evidence to support that early
treatment would be beneficial.

15. Timing of Treatment for Class III Malocclusion
• In summary
 Proffit contended that treatment should start as soon as
possible after Class III malocclusion is diagnosed. He pointed
to an ideal age of 8 years.
 Turpin developed a list of positive and negative factors that
helped decision making on developing Class III malocclusions
and these guidelines were reviewed by Campbell for deciding
when to intercept Class III malocclusion.
• Turpin suggested that early interceptive treatment of Class III
malocclusion should be considered for patients who presented
with positive characteristics as mentioned.
• The author also recommended that individuals with negative
characteristics should delay treatment until the completion of
growth

16. Timing of Treatment for Class III Malocclusion
In summary,
Table. Turpin’s positive and negative factors for decision
making for interception of developing Class III malocclusion
Negative factors
Positive factors
Divergent facial type
No anteroposterior shift
Asymmetrical growth of condyle
Growth completed
Severe skeletal disharmony
Poor cooperation expected
Familial pattern established
Poor facial esthetics
Convergent facial type
Anteroposterior functional shift
Symmetrical condyle growth
Young subject with remaining growth
Mild skeletal disharmony
Good cooperation expected
No familial prognathism
Good facial esthetics

17. Appliances for Treatment of Class III Malocclusion
• A number of appliances have been used to correct a Class III
skeletal discrepancy, but there is little evidence available on
their effectiveness in the long term.
• According to the systematic review
• There is a moderate amount of evidence to show that early
treatment with a facemask results in positive improvement for
both skeletal and dental effects in the short term.
• However, there was lack of evidence on long-term benefits.

18. Appliances for Treatment of Class III Malocclusion
• There is some evidence with regard
to the chincup, improvement for both skeletal
and dental effects in the short & long term ,
but the studies had a high risk of bias.
 They recommended that chincap use
must be continued until the completion
of facial growth.
 Further high-quality, long-term studies are required to
evaluate the early treatment effects for Class III malocclusion
patients.

19. Canine transmigration analysis
Treatment Approaches In
Class III Malocclusion

20. Orthognathic surgery
Growth Modification
Orthodontic correction
(Camouflage)
Treatment
Approaches
C
B
A
According To Dental Age

21. Growth modification

22. Growth modification
(In growing patient )
 Deficient maxillary growth
 Excessive mandibular growth
 Combination of both
A

23. Excessive mandibular growth
Chin cup
I
It has been found that chin cup
therapy does not restrain
mandibular growth but redirects
the mandible growth vertically,
causing a backward rotation of
the mandible.

24. Deficient maxillary growth
Reverse-pull headgear
(face mask)
1I
Myofunctional Appliance
Twin block, Frankle III

25. Functional appliances
 Functional appliances have been used to modify the skeletal
pattern by enhancing the growth of the maxilla and restricting
or redirecting the growth of the mandible.
 Current research suggests that functional appliances can
successfully correct a developing Class III malocclusion, but
they have principally dentoalveolar effects, with minimal
or no effects on the underlying skeletal pattern.
 Evidence from a recent systematic review suggests that the
FR III might restrict mandibular growth but not stimulate
forward movement of the maxilla.

26. Canine transmigration analysis
A New Appliance for Class
III Treatment in Growing
Patients

27. 1. Protraction headgear and Rapid Maxillary
Expansion appliance
 Facemask treatment is the most frequently used treatment
protocol for this anomaly
 This orthopedic treatment produces the most dramatic results
in the shortest period of time.

28. 1. Protraction headgear and Rapid Maxillary
Expansion appliance
 Many authors demonstrated that the desired forward
movement of the maxilla is accompanied by a downward
mandibular movement which also determines a clockwise
rotation of the mandible. The overall effect appears to be an
increase in vertical dimensions of the lower third of the face
that is obviously inappropriate for patients with increased
vertical skeletal relationships.
 Therefore, the control of vertical dimension appears to be a
key objective in Class III hyperdivergent patients.

29. 2. Pushing Splints 3 appliance
 Pushing Splints 3 (PS3) device was recently introduced for
the treatment of Class III malocclusion in children.
 The PS3 controlled better mandibular divergency reducing
the clockwise rotation in patients with higher mandibular
inclination.
 That is able to correct sagittal discrepancy with a good
control of the vertical growth. And reduce the clockwise
rotation in patients with higher mandibular inclination.
 This could be useful in the treatment of Class III
hyperdivergent patients

30. 2. Pushing Splints 3 appliance
Appliance Design
 The appliance consists of
 two acrylic splints
 and a Forsus™ L-pin module per
side.
 The Forsus™ L-pin modules are
used in order to deliver a force of
200 g per side in a forward direction
to the upper splint and in a backward
direction to the lower splint.
 In an opposite way from Class III elastics, the vertical
component of the force delivered by the Forsus™ L-pin
module is directed upward and forward in the maxilla and
downward and backward in the mandible.

31. 3. Carriere Class III Motion Appliance
Carriere Motion 3D Class III Correction Appliance
 device was introduced for the treatment of Class III
malocclusion
 The device shifts posterior teeth backward, eventually
reaching a Class I malocclusion.
 In a short time (three to five months) the small apparatus is
removed and full-orthodontic treatment can begin.

32. 3. Carriere Class III Motion Appliance
Appliance Design
 The anterior segment has a pad that bonds directly to the
lower canine, with a hook for attachment of Class III elastics.
 An arm extends distally over the two lower premolars, with a
slight curve following the contours of the dental arch, and is
bonded to the lower first molar by means of a distal pad.
 This rigid, half-round arm controls the lower canines while
directing movement longitudinally.
 the posterior segment is flat to avoid interference with the
maxillary teeth or brackets.

33. 3. Carriere Class III Motion Appliance

34. 3. Carriere Class III Motion Appliance
• Treatment Sequence
• Stage one with the Carriere Class III Motion Appliance
involves treating the malocclusion to a Class I platform by
distalizing each mandibular posterior segment, from canine to
molar, as a unit.
• The mandible is simultaneously repositioned for an improved
sagittal relationship by counterclockwise movement of the
posterior occlusal plane. By the end of stage one, when the
Class I platform is achieved, the lower canines will have been
distalized enough to provide space for proper repositioning of
the lower incisors, as determined by the diagnosis. The
appliance will also have intruded the lower molars while
extruding the canines - both necessary in Class III correction
to change the mandibular occlusal plane and distally
reposition the mandible for a better functional and esthetic
relationship.

35. 4.Bone-Anchored Maxillary Protraction (BAMP)
 Bone anchored protraction devices using mini-implants can
also be used to minimize the side effects associated with
maxillary expansion and protraction.
 Bone-anchored maxillary protraction (BAMP) was recently
developed by H.J. De Clerck and his group. Orthopedic
traction is applied to the maxilla with miniplates;

36. 4.Bone-Anchored Maxillary Protraction (BAMP)
 Bone anchored protraction devices using mini-implants can
also be used to minimize the side effects associated with
maxillary expansion and protraction.
 Bone-anchored maxillary protraction (BAMP) was recently
developed by H.J. De Clerck and his group. Orthopedic
traction is applied to the maxilla with miniplates;

37. Orthodontic correction
(Camouflage)

38. Orthodontic correction(camouflage)
(In non-growing patient)
(with no concern about facial appearance)
Treatment of Class III Cases
with Temporary Anchorage
Conventional Edgewise
Treatment with Or
without Extraction
B

39. A -Conventional Edgewise Treatment without Extraction
 Techniques Of Camouflage Treatment :
1- Non-extraction :
• Procline upper incisors, retrocline lower incisors (it is
unwise to procline the upper incisors beyond 120 degrees to the
maxillary plane or retrocline the lower incisors beyond 80
degrees to the mandibular plane.)

40. A -Conventional Edgewise Treatment with or without Extraction
1- Non-extraction :
• Expansion in upper arch to relieve crowding, eliminate
crossbites and mandibular displacements

41. A -Conventional Edgewise Treatment with Extraction
2.Option of extraction :
 It depend on the severity of the skeletal discrepancy.
I. Extraction of lower first premolars

42. A -Conventional Edgewise Treatment with or without Extraction
2.Option of extraction :
II. Extraction of a single lower incisor:
If the upper arch is well-aligned but space is required to align
and retrocline the lower incisors, extraction of a single lower
incisor can be an option (Zachrisson 1999).

43. B-Treatment of Class III malocclusion with
Temporary Anchorage

44. B-Treatment of Class III malocclusion with TAD
 is a nonextraction camouflage treatment modality for Class
III malocclusion, who did not accept surgical or extraction
treatment options.
I- Mandibular arch distalization by miniscrew
 From a biomechancal standpoint, placing a TAD in the
retromolar area is the most effective way for
 en masse distalization of the mandibular dentition.

45. B-Treatment of Class III malocclusion with TAD
 I- Mandibular arch distalization by miniscrew
 However, placing a TAD in the retromolar area is
 contraindicated if there is lack of attached gingiva and
reduced accessibility to the retromolar area.

46. B-Treatment of Class III Cases with Temporary Anchorage
I- Mandibular arch distalization
 Alternative solution is the placement of a miniscrew in the
interradicular area between the first and second molar or first
molar and second premolar.
 The limitation of this location is the proximity of the roots
of teeth which may be injured either during the insertion of the
TAD or the possibility of the
roots contacting the TAD when
the mandibular dentition
is distalized.

47. B-Treatment of Class III Cases with Temporary Anchorage
I- Mandibular arch distalization
 Alternative solution is the placement of a miniscrew in the
interradicular area between the first and second molar or first
molar and second premolar.
 The limitation of this location is the proximity of the roots
of teeth which may be injured either during the insertion of the
TAD or the possibility of the
roots contacting the TAD when
the mandibular dentition
is distalized.

48. B-Treatment of Class III Cases with Temporary Anchorage
I- Mandibular arch distalization
 Miniplates can be placed instead of miniscrews in the
mandibular posterior area to serve as absolute anchorage for
en masse distalization of the mandibular dentition.
 However, miniplates require flap surgery for both their
placement and removal with a longer healing period and more
pain and discomfort than with miniscrews.

49. B-Treatment of Class III Cases with Temporary Anchorage
I- Mandibular arch distalization
 A novel approach that overcomes the limitation of TADs in the
above-mentioned locations and can still bring about
predictable en masse distalization of mandibular dentition
recommended by Chang and Roberts. This involves the use
of an extra-alveolar miniscrew placed in the buccal shelf of
the mandible.
 The failure rate of this approach is reported to be as less as
7% and does not require predrilling and can withstand a load
up to 14 oz.

50. B-Treatment of Class III Cases with Temporary Anchorage
I- Mandibular arch distalization
 Since the success rate of TADs placed in the mandible is
significantly lower than the TADs placed in the maxilla, some
clinicians prefer to place a TAD in the maxilla between the
roots of the second premolar and the first molar and engage
Class III elastics from the TAD to the anterior mandibular
dentition.
 This approach is a compromise because the results depend
completely on patient cooperation.

51. Orthognathic surgery

52. Orthognathic surgery
(In non-growing patient )
Mandible
1- Sagittal split ramus osteotomy
(SSRO)
2- Intraoral vertical ramus osteotomy
(IVRO) or vertical subsigmoid
osteotomy (VSSO) or vertical or oblique
subcondylar osteotomy (VSO).
3- mandibular step osteotomy .
Maxilla
1- Surgically assisted rapid palatal
expansion (SARPE)
2- Le Fort I (total maxillary osteotomy)
C

53. Take a home massage

54. Class III Malocclusion
Surgery Camouflage
Edgewise
Treatment of
TAD
Growth
modification
1- Myofunctional appliance
2- Face mask
3- Pushing splint 3
4- Carriere Class III
5- BAMP
Exo.
Non-
Exo.

55. Thank you