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Case Report
6 (
5
); 261-264
doi:
10.4103/2321-1407.190741
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Management of skeletal Class III malocclusion with reverse pull headgear in a growing individual

Department of Orthodontics, Altamash Institute of Dental Medicine, Karachi, Pakistan
Consultant at Dental Care Orthodontics Clinic, Karachi, Pakistan
Address for Correspondence: Prof. Ambreen Afzal, Department of Orthodontics, Altamash Institute of Dental Medicine, Sunset Boulevard, Karachi, Pakistan. E-mail: drafazalehsan@gmail.com
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This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Afzal A, Sakrani H, Mahmood NE, Mehershahi K, Burney F. Management of skeletal Class III malocclusion with reverse pull headgear in a growing individual. APOS Trends Orthod 2016;6: 261-4.

Abstract

Skeletal Class III malocclusion is considered to be one of the most difficult orthodontic problems to treat. This malocclusion is associated with the retrognathic maxilla or prognathic mandible or sometimes a combination of both. The treatment of such cases requires an integrated approach and a comprehensive treatment plan including growth modification, dental camouflage, or orthognathic surgery. In a growing patient, orthopedic correction of skeletal Class III malocclusion with the help of a reverse pull headgear is crucial as it can reduce the chances of further surgical treatment to correct the skeletal discrepancy. This case report describes the management of skeletal Class III malocclusion in a 12-year-old female child with a retrognathic maxilla. The patient did not have any other genetic abnormality or significant known comorbidity. The treatment plan involved fixed orthodontic appliance therapy in combination with a reverse pull headgear for an orthopedic effect. This treatment was continued for 3 years, and well-aligned dental arches with a positive over jet were achieved at the conclusion of treatment. Using facemask therapy in conjunction with fixed orthodontic appliances has been a successful treatment option in growing children. Treatment should be carried out as early as possible to correct the skeletal discrepancy nonsurgically and achieve better results.

Keywords

Appliances
growth modification
integrated approach
malocclusion
orthopedic
retrognathic
reverse pull headgear
skeletal discrepancy
surgically

INTRODUCTION

Class III malocclusion is one of the most difficult problems to treat in the mixed dentition, often resulting in bilateral anterior and posterior cross-bites.[1] This malocclusion is most likely to be associated with a variety of environmental and genetic factors.[2,3] Prevalence of skeletal Class III malocclusion is greater among the Asian population as compared to Caucasians.[4] If left untreated, the skeletal discrepancy gets worse with time.

The dental and skeletal effects of maxillary protraction with a facemask during the mixed dentition phase have not been well documented in the literature. These cases are generally left untreated during the mixed dentition phase because of poor patient cooperation, leading to an increased skeletal discrepancy with time. Orthopedic therapy in the late-mixed or early permanent dentition can be successful, but the results are generally better when carried out in the deciduous or early-mixed dentition.[5,6] In this case-report, we describe clinical presentation, dental examination, radiological investigations, treatment plan, and outcomes of a 12-year-old female child with skeletal Class III malocclusion due to a retrognathic maxilla, seeking orthodontic treatment at a private orthodontic clinic.

Figure 1: Pretreatment extraoral and intraoral pictures
Figure 2: Pretreatment orthopantomogram radiograph
Figure 3: Pretreatment cephalogram radiograph
Figure 4: Reverse pull headgear
Figure 5: Posttreatment extra- and intra-oral pictures
Figure 6: Posttreatment cephalogram radiograph

CASE REPORT

A 12-year-old female patient reported to the orthodontic clinic, with a presenting complaint of a protruded lower jaw and irregular placement of the front teeth. The patient did not have any other dental complaint or prior history of seeking dental care. The patient did not have any known comorbidity or genetic disorder or syndrome. There was no significant medical or surgical history and was not taking any medication at the time of presentation. Extraoral examination revealed a leptoprosopic face form with a concave profile and an obtuse nasolabial angle. The patient had a minimal smile line with decreased incisal visibility. Intraoral examination showed a Class III molar and canine relationship, bilateral anterior and posterior cross-bites along with a reverse overjet of 4 mm. Deciduous second molars were present bilaterally in the lower arch and unilaterally on the left side in the upper arch. No other significant abnormalities were observed during intraoral examination [Figure 1]. An orthopantogram and lateral cephalogram were carried out as part of routine radiological investigations. The orthopantomogram confirmed the presence of deciduous teeth and their permanent successors [Figure 2]. Cephalometric evaluation revealed an SNA of 70° and an SNB of 81°, indicating that the patient had a skeletal Class III malocclusion because of a retrognathic maxilla with an ANB of −11°. The upper incisors had normal inclination, indicated by a UISN angle of 99° while the lower incisors were retroclined according to the IMPA value of 72° [Table 1 and Figure 3]. Based on the extraoral/intraoral findings and the radiographic investigations carried out, a comprehensive and detailed treatment plan was made. The initial treatment plan involved fixed orthodontic appliance therapy. A few weeks after that, a reverse pull headgear was included in the treatment plan to achieve the ideal orthopedic effect required for the correction of skeletal discrepancy. The reverse pull headgear was attached to two hooks incorporated in the anterior region of the maxillary dentition. The approximate duration of wear for the reverse pull gear was 14–15 h as reported by the patient [Figure 4]. During this treatment phase, the patient was advised to wear Class III elastics for better results. The treatment continued for 3 years and led to improved facial esthetics [Figure 5]. The posttreatment cephalometric evaluation revealed an SNA of 79° and an SNB of 78°, indicating that the patient’s malocclusion was primarily corrected by maxillary protraction and clockwise rotation of the mandible, correcting the ANB from −11° to +1°. An increase in the values of SNMP from 31° to 38° and FHMP from 20° to 26° confirmed the clockwise rotation of the mandible [Figure 6]. At the end of treatment, well-aligned dental arches with a positive overjet and a Class I molar and canine relationship were achieved [Figures 5 and 7].

Table 1: Pre- and post-treatment cephalometric values
Measurements Normal Pretreatment Mid treatment
SNA (°) 82±2 70 79
SNB (°) 78±2 81 78
ANB (°) 2±2 −11 1
Mc-A (mm) 1±2 −7 +1
Mc-Po (mm) −3±4 +11 +5
UISN (°) 102±4 99 102
IMPA (°) 90 72 74
SNMP (°) 32±4 31 38
FHMP (°) 25±4 20 26
Figure 7: Posttreatment orthopantomogram radiograph

DISCUSSION

During orthopedic treatment, an attempt is made to change the morphology of craniofacial skeleton to correct the skeletal discrepancy. The reverse pull headgear provides a direct anterior force leading to downward and forward displacement of the maxilla.[7] This orthopedic effect allows the mandible to rotate downward and backward, increasing the lower facial height and acting as a major contributing factor in establishing a positive overjet. This is accompanied by an increase in the upper incisor inclination and a decrease in the lower incisor inclination aiding in the anterior cross-bite correction.[8] According to a study by Williams et al., the average anterior movement of point A after the orthopedic treatment was 1.54 mm and that of maxillary teeth was 2.73 mm, confirming that the positive overjet obtained was due to both skeletal and dental effects.[9] Orthodontic fixed appliance therapy in combination with a reverse pull headgear for the correction of Class III malocclusion is believed to be more effective in early-mixed dentition as compared to late-mixed dentition.[10] Hence, the orthopedic correction of skeletal Class III malocclusion with the help of a reverse pull headgear in a growing patient is crucial as it aids in achieving a better esthetic profile and reduces the chances of further surgical treatment to correct the skeletal discrepancy.

CONCLUSION

Skeletal Class III malocclusions due to a retrognathic maxilla in a growing individual can be successfully treated using fixed orthodontic appliances in combination with a reverse pull headgear to achieve the desired orthopedic effect. Careful case selection, patient cooperation, and long-term stabilization ensure ideal treatment results and stability. This treatment protocol is believed to be more effective in the early-mixed dentition as compared to late-mixed dentition and reduces the chances of further surgical treatment to correct the skeletal discrepancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. . Handbook of Orthodontics. Chicago, IL: Yearbook Publishers Inc.. 564-77
    [Google Scholar]
  2. , . Anterior crossbite correction with a series of clear removable appliances: A case report. J Esthet Restor Dent. 2009;21:149-59
    [Google Scholar]
  3. , . Treatment of anterior cross-bites in the early mixed dentition. J Can Dent Assoc. 1992;58:574-5
    [Google Scholar]
    :578-5
    [Google Scholar]
  4. , , , . Prevalence of malocclusion and its traits in Delhi children-I. J Indian Orthod Soc. 1995;26:98-103
    [Google Scholar]
  5. , , . Cephalometric variables predicting the long-term success or failure of combined rapid maxillary expansion and facial mask therapy. Am J Orthod Dentofacial Orthop. 2004;126:16-22
    [Google Scholar]
  6. , , . Cephalometric variables to predict future success of early orthopedic class III treatment. Am J Orthod Dentofacial Orthop. 2005;127:301-6
    [Google Scholar]
  7. , . Correction of a skeletal class III with anterior cross bite using maxillary protraction therapy. JSM Dent. 2014;2:1028
    [Google Scholar]
  8. , , , , , . Nonsurgical treatment of a patient with a class III malocclusion. Am J Orthod Dentofacial Orthop. 2006;129:S111-8
    [Google Scholar]
  9. , , , . Combined rapid maxillary expansion and protraction facemask in the treatment of class III malocclusions in growing children: A prospective long-term study. Semin Orthod. 1997;3:265-74
    [Google Scholar]
  10. , , . Clinical considerations in the use of protraction headgear. J Clin Orthod. 1992;26:87-91
    [Google Scholar]
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