Orthognathic Camouflage With TADs for Improving Facial Profile in Class III MalocclusionERIC

1. 243
16
Orthognathic Camouflage With TADs
for Improving Facial Profile in Class III
Malocclusion
ERIC JW. LIOU
T
he treatment of Class III malocclusion includes sur-
gical orthodontics,1–4 or orthodontic camouflage
treatment.5–7 Orthodontic camouflage treatments,
such as protraction of upper dentition and/or retraction of
lower dentition through extraction or nonextraction ther-
apy, improve the anterior crossbite in patients with Class III
malocclusion.8–11 The scope of Class III orthodontic cam-
ouflage treatment expands after the temporary anchorage
devices (TADs) have been included.9–11
Orthodontic retraction of lower dentition also retracts
lower lip and relatively worsens chin projection and man-
dibular prognathism.12 The goal of Class III orthodontic
camouflage treatment should be to improve both occlu-
sion and facial profile. However, mandibular prognathism
is difficult to camouflage orthodontically.
An innovative concept of “orthognathic camou-
flage”13 by orthodontic backward rotation of mandible,
to decrease chin projection, in treating either growing
or adult patients with Class III malocclusion has been
proposed. This concept is not new. It originated from
the clockwise rotation of maxillomandibular complex
by orthognathic surgery, for the improvement of Class
III facial profile,14–16 as well as from the opposite, the
orthodontic intrusion of posterior teeth with TADs,
for the correction of anterior openbite and improve-
ment of mandibular retrognathism in Class II openbite
patients.17,18
Orthognathic camouflage, by backward rotation of
mandible, for patients with Class III malocclusion, is to
extrude the upper and/or lower dentitions, for improv-
ing upper incisor show and smile arc, and subsequently
to backward rotate the mandible to decrease chin pro-
jection and mandibular prognathism. Three techniques,
including bimaxillary or single-dentition extrusion with
or without TADs, have been developed. They could be
used in either nonextraction or extraction, growing or
adult patients.
Bimaxillary Extrusion Without TADs
This is a technique of orthodontic backward rotation of
mandible, with bite raisers and vertical elastics. The strategy
is to place bite raisers/blocks on posterior teeth to open the
bite and backward rotate the mandible to the planned posi-
tion, and then the anterior openbite is closed, via bimaxil-
lary extrusion of the upper and lower dentitions, by using
intermaxillary vertical elastics (Figs. 16.1 and 16.2).
Preparation
A segmental maxillary archwire from second premolar to
second premolar with anterior labial crown torque is placed,
and another two segmental archwires are placed on both
sides of the maxillary first and second molars. A transpalatal
arch (TPA) is placed to consolidate the maxillary posterior
teeth. A continuous archwire and a lingual holding arch are
then placed in the mandibular dentition.
Placement of Bite Raisers to Backward Rotate
Mandible
The material for bite raisers could be a light-cured compos-
ited resin or glass ionomer (GI) band cement. For the ease
of saliva control, bite raisers placement, and their removal,
it is recommended to use light-cured GI band cement and
bond them on both sides of upper posterior teeth.
The occlusal surfaces of upper molars on both sides are
first cleaned with pumice powder, and then the central fos-
sae of the upper molars, but not the entire occlusal surface,
are conditioned with etching agent. The etching process at
the central fossae ensures retention of the bite raisers, with-
out dislodgement during treatment, and ease of removal
after treatment. The GI band cement is then added incre-
mentally on the occlusal surfaces of the upper molars until
2 to 3 mm bite opening at the anterior teeth.

2. 244 PART VII Management of Multidisciplinary and Complex Problems
A
• Fig. 16.1 The clinical procedure and case report of bimaxillary extrusion without TADs for backward
rotation of mandible and redirecting the mandibular growth in a 13-year-old female client with Class III
malocclusion. (A) The pretreatment extraoral, cone beam computed tomography (CBCT) images, and
intraoral photographs revealed inadequate upper incisor show, excessive lower incisor display, maxillary
hypoplasia, mandibular prognathism, and anterior crossbite;
Extrusion of Anterior Teeth to Close Anterior
Openbite
After placing the bite raisers, intermaxillary vertical elas-
tics are then applied between the upper and lower anterior
teeth. Patients are instructed to wear the intermaxillary
vertical elastics 14 to 20 hours per day, and arranged to
return to the clinic on a monthly basis. Increment of GI
band cement is added on the bite raisers to keep the bite
opened 2 to 3 mm, at each monthly visit, so that the man-
dible rotates backward incrementally to the planned posi-
tion or facial profile.
(Continued on next page)

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
B
C
• Fig. 16.1, cont’d (B) The anterior crossbite was first corrected by maxillary orthopedic protraction through
7-week of Alternate Rapid Maxillary Expansions and Constriction (Alt-RAMEC) with a double-hinged
expander and then a pair of intraoral protraction springs for 3 months. The expander was maintained for
another 3 months after the maxillary protraction; (C) The overall skeletal superimposition on cranial base
(pretreatment: silver color, postprotraction: green color) revealed the maxilla was protracted 3.0 mm, and
the mandible was displaced downward 4.0 mm and backward 2.0 mm.
Extrusion of Posterior Teeth
After the mandible has incrementally backward rotated
to the planned position or facial profile and the upper
and lower anterior teeth have been brought into occlu-
sion, the bite raisers are removed. Intermaxillary poste-
rior vertical elastics, together with TPA lateral expansion,
are then applied to extrude the upper molars, without
palatal tipping and decreasing maxillary intermolar
width.
After the upper and lower posterior teeth have occluded,
a continuous maxillary archwire is then placed to replace the
segmental archwires in the maxillary dentition.
(Continued on next page)

4. D
E
F
• Fig. 16.1, cont’d (D) Bite raisers were placed incrementally on the upper posterior teeth at each appointment
to open the bite 2 mm at the anterior teeth and to redirect the mandible downward and backward, and anterior
vertical elastics were applied for bimaxillary extrusion of the anterior teeth and premolars after the upper and
lower dentitions were aligned; (E) The bite raisers were removed and posterior vertical elastics were applied for
extruding the posterior teeth, after 4 months of redirecting the mandibular growth; (F) The posterior teeth of both
upper and lower dentitions were brought into occlusion after 5 months of posterior vertical elastics;
(Continued on next page)

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
G
• Fig. 16.1, cont’d (G) The posttreatment extraoral, CBCT images, and intraoral photos at the age of 15
years revealed a full smile arc and good amount of upper incisor show, without excessive lower incisor
display, and a Class I facial profile;
(Continued on next page)

6. 248 PART VII Management of Multidisciplinary and Complex Problems
H
I
• Fig. 16.1, cont’d (H) The overall skeletal superimposition on cranial base (postprotraction: green color,
posttreatment: red color) revealed the maxilla remained stable, the maxillary posterior teeth were extruded
5.0 to 6.0 mm, the maxillary anterior teeth were extruded 2.0 to 3.0 mm, and the mandible was further
redirected downward 5.0 mm and backward 3.0 mm. (I) The 1-year posttreatment extraoral and intraoral
photos at the age of 16 years revealed stable clinical results, without obvious changes of facial profile and
occlusion.

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
A
B
C
D
• Fig. 16.2 The overall effects of maxillary protraction and redirection of mandibular growth of the case
reported in Fig. 16.1. (A) The overall skeletal superimposition on cranial base (pretreatment: silver color,
posttreatment: red color) revealed the maxilla was protracted 3.0 mm, and the mandible was redirected
and grew downward 9.0 mm and backward 5.0 mm, rather than downward and forward; (B) The overall
soft tissue superimposition based on overall skeletal superimposition on cranial base revealed the soft
tissue at the midface and paranasal area was 1.5 mm fuller, and the chin projection reduced 5.0 mm back-
ward and 8.0 mm downward; (C) The cranial base superimposition without mandible revealed the maxillary
was protracted 3.0 mm, the maxillary molars were extruded 5.0 to 6.0 mm, and the maxillary anterior teeth
were extruded 3.0 mm; (D) The mandibular superimposition illustrated the lower dentition was extruded
5.0 to 6.0 mm, and the mandibular condyles grew 4.0 mm.

8. 250 PART VII Management of Multidisciplinary and Complex Problems
A
• Fig. 16.3 The clinical procedure and case report of single-dentition extrusion with TADs in mandible for
backward rotation of mandible and redirecting mandibular growth in a 14-year 3-month-old male client
with Class III malocclusion and bilateral cleft lip and palate. (A) The pretreatment extraoral, cone beam com-
puted tomography (CBCT) images, and intraoral photographs revealed depressed midface and paranasal
area, excessive chin throat length, maxillary hypoplasia, mandibular prognathism, and anterior crossbite;
Single-Dentition Extrusion With TADs in
Mandible
This is a technique of orthodontic backward rotation of
mandible with bite raisers, TADs in mandible, and verti-
cal elastics. The strategy is to achieve backward rotation of
mandible, without extruding lower anterior teeth, by using
TADs in the mandible (Figs. 16.3 and 16.4).
Insertion of TADs
The preparation procedure of this technique is the same
as the bimaxillary extrusion without TADs. To rotate the
mandible without extruding the lower dentition, TADs
are placed in the anterior of mandible. The TADs could be
inserted interdentally between mandibular canine and first
premolar on both sides.
(Continued on next page)

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
B
C
• Fig. 16.3, cont’d (B) The anterior crossbite was first corrected by maxillary orthopedic protraction
through 7-week Alternate Rapid Maxillary Expansions and Constriction (Alt-RAMEC) with a double-hinged
expander and then a pair of intraoral protraction springs for 3 months. The expander was maintained for
another 3 months after the maxillary protraction; (C) The overall skeletal superimposition on cranial base
(pretreatment: silver color, postprotraction: green color) revealed the maxilla was protracted 3.0 mm, and
the mandible was displaced downward 7.0 mm and backward 1.5 mm;
(Continued on next page)

10. D
E
F
• Fig. 16.3, cont’d (D) The TADs were inserted between the lower canine and first premolar at both sides,
bite raisers were placed incrementally on the upper posterior teeth at each appointment to open the bite 2
mm at the anterior teeth, and vertical elastics were applied between the lower TADs and upper dentition to
extrude the upper dentition and redirect mandibular growth; (E) The bite 6 months after redirecting man-
dibular growth; (F) The bite raisers were removed and posterior vertical elastics were applied for extruding
the posterior teeth for 15 months;
(Continued on next page)

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
G
• Fig. 16.3, cont’d (G) The posttreatment extraoral, CBCT images, and intraoral photos at the age of 16
years and 9 months revealed a better smile arc, and upper incisor show and improvement of facial profile;
(Continued on next page)

12. 254 PART VII Management of Multidisciplinary and Complex Problems
H
• Fig. 16.3, cont’d (H) The overall skeletal superimposition on cranial base (postprotraction: green color,
posttreatment: red color) revealed the maxilla grew 1.0 mm forward further, although there were anterior
teeth dental relapse. The maxillary dentition was extruded 4.0 to 5.0 mm at the anterior and 6.0 to 7.0
mm at the posterior, and the mandible was further redirected downward 4.0 mm and backward 1.0 mm.
Placement of Bite Raisers and Extrusion of
Upper Anterior Teeth
The placement of the bite raisers is the same as the procedure
of bimaxillary extrusion without TADs. After insertion of the
TADs in mandible and placement of bite raisers on the occlu-
sal surfaces of maxillary posterior teeth, intermaxillary vertical
elastics are then applied between the upper anterior teeth and
the lower TADs for extruding the upper dentition.
Extrusion of Posterior Teeth
This procedure is the same as the extrusion of posterior teeth
in procedure of bimaxillary extrusion without TADs.
Single-Dentition Extrusion With TADs in
Maxilla
This is a technique of orthodontic backward rotation of
mandible, with TADs in maxilla, without bite raisers and
vertical elastics. The strategy is to achieve backward rota-
tion of mandible, without extruding lower anterior teeth by
using TADs and extruding springs in the maxilla (Figs. 16.5
and 16.6).
Insertion of TADs
To rotate the mandible without extruding the lower denti-
tion and without bite raisers, TADs are placed in the buccal
side of maxilla. The TADs could be inserted interdentally
between the maxillary canine and first premolar, between
the premolars, or between the first molar and premolar on
both sides in extraction cases.
After insertion of the TADs, a pair of extruding springs
(0.019 × 0.025 titanium molybdenum alloy [TMA]) is
placed in the TADs, for extruding the entire maxillary
dentition. The extruding spring is composed of two arms.
One arm is for the extrusion of maxillary anterior, and it is
hooked on the main archwire, between the central incisors,
to avoid occlusal cant caused by unbalancing force, from
each side of the extruding springs. The other arm is for the
extrusion of maxillary posterior teeth, and it is hooked on
the main archwire between the first and second maxillary
molars.
The TADs insertion sites are better symmetrically at the
same position, on each side, so that the extruding springs
are equal in length and force to avoid causing occlusal cant.
A removable and adjustable TPA (0.032 TMA) should be
used to avoid palatal tipping of posterior teeth during molar
extrusion. Buccal crown torque and lateral expansion are
added on the TPA.
Maxillary Vertical Development in Class III
Patients
Either bimaxillary or single-dentition extrusion extrudes
maxillary dentition and also develops maxillary vertical
height, which improves the smile and upper incisor show

13. A
B
C
D
• Fig. 16.4 The overall effects of maxillary protraction and redirection of mandibular growth with lower
TADs of the case reported in Fig. 16.3. (A) The overall skeletal superimposition on cranial base (pretreat-
ment: silver color, posttreatment: red color) revealed the maxilla was protracted and grew forward 4.0
mm, and the mandible was redirected and grew downward 11.0 mm and backward 2.5 mm, rather than
downward and forward; (B) The overall soft tissue superimposition based on overall skeletal superimposi-
tion on cranial base revealed the soft tissue at the midface and paranasal area was 2.5 mm fuller, and the
chin projection reduced 6.0 mm backward and 11.0 mm downward; (C) The cranial base superimposition
without mandible revealed the maxillary was protracted and grew 4.0 mm forward, the maxillary posterior
teeth were extruded 8.0 mm, and the maxillary anterior teeth were extruded 5.0 mm; (D) The mandibular
superimposition illustrated the lower posterior teeth were extruded and erupted 5.0 to 6.0 mm, the lower
anterior teeth were extruded and erupted 2.0 mm, and the mandibular condyles grew 8.0 mm on the right
and 6.0 mm on the left.

14. 256 PART VII Management of Multidisciplinary and Complex Problems
A
• Fig. 16.5 The clinical procedure and case report of single-dentition extrusion with TADs in maxilla for
backward rotation of mandible and orthognathic camouflage in a 27-year-old female with Class III maloc-
clusion. (A) The pretreatment extraoral, cone beam computed tomography (CBCT) images, and intraoral
photographs revealed excessive chin throat length, mandibular prognathism, inadequate upper incisors
show, excessive lower incisors display, flat smile arc, and anterior cross bite;
in patients with Class III malocclusion. Maxillary hypo-
plasia and/or mandibular prognathism are the most two
common features in patients with Class III malocclusion.
The maxillary hypoplasia includes sagittal and/or vertical
deficiency. Unfortunately, the Class III orthodontic camou-
flage treatment usually focuses on the sagittal improvement
of anterior crossbite,5–7 but seldom on the improvement of
maxillary vertical deficiency.
Orthodontic extrusion or force eruption has been
used successfully for implant site development in alveo-
lar vertical bone height.19–21 Similarly, the extrusion of
maxillary dentition could develop the maxillary alveolar
vertical bone height and subsequently improve the max-
illary incisors show and smile arc, backward rotate the
mandible, reduce chin prominence, and shorten the chin
throat length.
(Continued on next page)

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
B
C
• Fig. 16.5, cont’d (B) The anterior crossbite was first improved by alignment and leveling of the upper
and lower dentitions with bite raisers at the upper posterior teeth for jumping the bite. Then, TADs were
inserted between the upper canine and first premolar at both sides; (C) pairs of extruding springs (0.019
× 0.025 TMA) were placed in the TADs for extruding upper dentition. The upper archwire was built in with
anterior teeth labial torque, for avoiding palatal tipping during extrusion, and a transpalatal arch (TPA) was
built in with lateral expansion and parallel molar torque for avoiding palatal tipping and decreasing buccal
overjet during extrusion;
Comparisons and Indications of
Bimaxillary Extrusion and Single-Dentition
Extrusion
The bimaxillary extrusion extrudes both the maxillary
and mandibular dentitions. On the other hand, the sin-
gle-dentition with TADs in mandible or maxilla extrudes
mostly maxillary dentition, but not the mandibular den-
tition. Bimaxillary extrusion has been reported to be
more efficient and effective than single-dentition extru-
sion in rotating the mandible downward and backward
in growing Class III patients.13 It has more mandibular
backward rotation and orthognathic camouflage than the
single-dentition extrusion. Single-dentition extrusion
might spend more time in rotating the mandible clock-
wise to the same extent the bimaxillary extrusion does.
Bimaxillary extrusion extrudes lower incisors and may
unfavorably increase lower incisor show, especially in adult
(Continued on next page)

16. D
E
• Fig. 16.5, cont’d (D) The extruding springs and the TPA lateral expansion were applied for 8 months; (E)
The posttreatment extraoral, CBCT images, and intraoral photos revealed a better smile arc, upper incisor
show, and improvement of facial profile.

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CHAPTER 16 Orthognathic Camouflage With TADs for Improving Facial Profile in Class III Malocclusion
A
B
C
D
• Fig. 16.6 The overall effects of orthognathic camouflage of the case reported in Fig. 16.5. (A) The overall
skeletal superimposition on cranial base (pretreatment: silver color, posttreatment: red color) revealed the
maxillary dentition was extruded 4.0 to 5.0 mm, and the mandible was rotated downward 5.0 mm and
backward 4.0 mm; (B) The overall soft tissue superimposition based on overall skeletal superimposition
on cranial base revealed the chin projection reduced 3.0 mm backward and 3.0 mm downward. The chin
throat length decreased 3.0 mm; (C) The cranial base superimposition without mandible revealed the
maxillary dentition was extruded 4.0 to 5.0 mm; (D) The mandibular superimposition illustrated the lower
second molars were intruded 1.5 mm, lower premolars were extruded 1.5 mm, and the lower anterior
teeth were intruded 1.5 mm. The lower curve spee was leveled.

18. 260 PART VII Management of Multidisciplinary and Complex Problems
patients. Interestingly, we have observed clinically that
the lower incisor show remained similar or even was less
in growing patients treated with bimaxillary extrusion (see
Fig. 16.1). This could be caused by the growth of soft tis-
sue compensating for the extrusion of lower incisors. Thus,
due to the mandibular growth, growing patients are better
treated by bimaxillary extrusion. For the adult patients with
excessive lower incisor show, bimaxillary extrusion could be
contraindicated.
On the other hand, bite raisers open the bite but also
interfere with eating. This might be not a big problem for
growing patient but could be a problem for adult patients.
The single-dentition extrusion with TADs in maxilla would
be friendlier for adult patients.
Backward rotation of mandible also increases anterior
facial height and might lead to lip incompetence. There-
fore backward rotation of mandible should be stopped
when lip incompetence is developing. Orthodontic back-
ward rotation of mandible is indicated in Class III patients
with short face, low angle, maxillary vertical deficiency,
or overclosure, and it might not be indicated in Class III
patients with long face, high angle, openbite, or lip incom-
petence. Class III patients with lip incompetence caused
by dentoalveolar protrusion could still be candidates for
extraction therapy.
The Stability of Orthodontic Extrusion
Although the long-term stability of orthodontic extru-
sion has yet to be well revealed, the 1 to 3 years post-
treatment results were reported stable in some case
reports.22–24 In contrast, the stability of orthodontic
intrusion has been documented and the 3 to 4 years post-
treatment relapse of orthodontic intrusion of posterior
teeth was 13.37% to 22.88%.25,26 The long-term stabil-
ity of orthodontic extrusion could be similar to that of
orthodontic intrusion, and overcorrection is commended
for the backward rotation of mandible in patients with
Class III malocclusion.
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