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Ngan, Peter Treatment of Anterior Crossbite.Pdf AAO/AAPD Conference Scottsdale, Arizona, 2018 Speaker: Dr. Peter Ngan Lecture Date: Sunday, February 11, 2018 Lecture Time: 8:15 – 9:00 am. Lecture Title: “Treatment of Anterior Crossbite” Lecture Description Anterior crossbite can be caused by a simple forward functional shift of the mandible or excessive growth of the mandible. Chin cups and facemasks have been advocated for early treatment of skeletal Class III malocclusions. Long-term data showed greater benefits if treatment was started in the primary or early mixed dentitions. Is the benefit worth the burden? Will the final result of two stage treatment be better than that of a single course of treatment at a later stage? If so, how do we diagnose Class III problems early? Can we predict the outcome of early Class III treatment? The presenter will discuss these questions with the help of long-term treatment records. Lecture Objectives • Participants will learn how to diagnose Class III problems early • Participants will learn how to manage patients with anterior crossbite • Participants will learn the long-term treatment outcome of patients having anterior crossbite corrected in the primary and early mixed dentitions. CENTENNIAL SPECIAL ARTICLE Evolution of Class III treatment in orthodontics Peter Ngana and Won Moonb Morgantown, WVa, and Los Angeles, Calif Angle, Tweed, and Moyers classified Class III malocclusions into 3 types: pseudo, dentoalveolar, and skeletal. Clinicians have been trying to identify the best timing to intercept a Class III malocclusion that develops as early as the deciduous dentition. With microimplants as skeletal anchorage, orthopedic growth modification became more effective, and it also increased the scope of camouflage orthodontic treatment for patients who were not eligible for orthognathic surgery. However, orthodontic treatment combined with orthognathic surgery remains the only option for patients with a severe skeletal Class III malocclusion or a craniofacial anomaly. Distraction osteogenesis can now be performed intraorally at an earlier age. The surgery-first approach can minimize the length of time that the malocclusion needs to worsen before orthognathic surgery. Finally, the use of computed tomography scans for 3-dimensional diagnosis and treatment planning together with advances in imaging tech- nology can improve the accuracy of surgical movements and the esthetic outcomes for these patients. (Am J Orthod Dentofacial Orthop 2015;148:22-36) n 1899, Angle1 was the first to classify malocclusions In 1966, Tweed2 classified Class III malocclusions into Class I, Class II, and Class III based on the rela- into 2 categories: category A was defined as a pseudo- I fi tionship of the rst molars and the alignment (or Class III malocclusion with a conventionally shaped lack of it) of the teeth relative to the line of occlusion. mandible, and category B was defined as a skeletal Class Almost immediately, it was recognized that the Angle III malocclusion with a large mandible or an underdevel- classification was not complete because it did not oped maxilla. Moyers3 further classified malocclusions include important characteristics of the patient's prob- according to the cause of the problem: osseous, lem. Gradually, Angle's classification numbers were muscular, or dental in origin. Moyers emphasized the extended to refer to the skeletal jaw relationship and need to determine whether the mandible, on closure, is the pattern of growth other than the molar relationship. in centric relation or in a convenient “anterior” position Thus, a Class III jaw relationship meant that the for patients with neuromuscular or functional problems. mandible was positioned mesial to the maxilla. This Anterior repositioning generally results from a tooth was usually found in connection with a Class III molar contact relationship that forces the mandible in a for- relationship but occasionally could be a Class I molar ward position. Moyers suggested that a pseudo-Class relationship when the dental compensation overcame III malocclusion is a positional malrelationship with an the skeletal imbalance. A Class III growth pattern is acquired neuromuscular reflex. then defined as one with disproportionate forward The prevalence of Angle Class III malocclusions varies mandibular growth or deficient maxillary growth. greatly among and within populations, ranging from 0% to 26%.4 Pseudo-Class III malocclusions are found pri- marily in the deciduous and mixed dentitions. Approxi- aProfessor and chair, Department of Orthodontics, School of Dentistry, West Vir- mately 60% to 70% of anterior crossbites in the 8- to ginia University, Morgantown, WVa. fi b 12-year-old group were classi ed as pseudo-Class III Associate clinical professor and program director, Section of Orthodontics, 5 School of Dentistry, University of California, Los Angeles, Calif. malocclusions. A study excluding children under 11 All authors have completed and submitted the ICMJE Form for Disclosure of Po- years old found that the populations from Southeast tential Conflicts of Interest, and none were reported. Asian countries (Chinese and Malaysian) showed the Address correspondence to: Peter Ngan, Department of Orthodontics, West Vir- 6-9 ginia University, 1073 Health Science Center North, PO Box 9480, Morgantown, highest prevalence rate of 15.8%. Middle Eastern 10,11 WV 26506; e-mail, [email protected]. nations had a mean prevalence rate of 10.2%. Submitted, revised and accepted, April 2015. European countries had a lower prevalence rate of 0889-5406/$36.00 12,13 Copyright Ó 2015 by the American Association of Orthodontists. 4.9%, and the Indian population showed the 8,9,14 http://dx.doi.org/10.1016/j.ajodo.2015.04.012 lowest prevalence rate of 1.2%. In white children, 22 Ngan and Moon 23 approximately 57% of the patients with either a normal Environmental factors that have been thought to in- or a prognathic mandible showed a deficiency in the fluence Class III malocclusion include habits, enlarged maxilla.15 In Asian countries such as Japan, patients tonsils, chronic mouth breathing leading to downward were found to have a significantly reduced anterior cra- and backward growth of mandible, abnormal tongue nial base, an obtuse gonial angle, and an increased lower and mandibular posture, endocrine disturbances, anterior face height. Backward rotation of the mandible posture, trauma, and nasal blockage.20 The role of these was necessary to coordinate the occlusion because of the factors, however, is based on only a few observations. small maxilla.16 The familial nature of mandibular prognathism was first reported by Strohmayer in 1937 as noted by Wolff EVOLUTION OF ORTHOPEDIC TREATMENT et al21 in their analysis of the Hapsburg family. However, In 1728, Fauchard was first to describe the bandeau, it is probable that the mandibular prognathism in the fl an expansion arch consisting of a horseshoe-shaped Hapsburg family was heavily in uenced by inbreeding, strip of precious metal to which the teeth were ligated. an autosomal recessive pattern, and other multifactorial It was refined by Bourdet, a dentist to the King of inheritance possibilities. Analyses of less inbred groups France; he was the first to practice “lingual orthodon- usually indicate an autosomal dominant mode of inher- tics,” expanding the arch from the lingual aspect. In itance with incomplete penetrance and variable expres- sivity in some families and multifactorial influences in 1771, Hunter took a particular interest in the anatomy 19 of the teeth and jaws. His text, The Natural History of others. the Human Teeth,17 presented the first clear statement of orthopedic principles. He established the difference TREATMENT OF PSEUDO-CLASS III between teeth and bone, and he gave the teeth names MALOCCLUSION fi such as cuspidati and bicuspidati. He was the rst to A pseudo-Class III malocclusion is characterized by describe the growth of the jaws, not as a hypothesis an anterior crossbite caused by a forward functional fi but as a sound, scienti c investigation. displacement of the mandible. In the mixed dentition, fi In 1802, Fox was the rst to give explicit directions the patient usually has a mesial step that is less than 3 for correcting irregularities of the teeth. He was particu- mm. The maxillary incisors are retroclined, and the larly interested in the use of an expansion arch and a mandibular incisors are proclined and spaced.22 When chincup. However, it was Kneisel, a German dentist to patients are guided into a centric relationship, they often fi Prince Charles of Prussia, who was the rst to use a show an end-to-end incisor relationship accompanied removable chin strap to treat patients with a prognathic by a forward shift of the mandible that we now call a mandible. functional Class III malocclusion. In most patients, it is fi For maxillary orthopedics, Angell was rst to open caused by retroclination of the maxillary incisors. Often, the median palatal suture with a split plate. Case showed there is a Class I molar relationship with a normal “ remarkable foresight in differentiating between dental mandibular appearance and a straight facial profile, malpositions” and “dentofacial imperfections,” compa- 18 disguising the skeletal discrepancy. rable to today's terms, dentoalveolar and skeletal. He An anterior crossbite and a mild skeletal Class III stressed facial esthetics in contrast to Angle's reliance malocclusion in the mixed dentition can be corrected “ on occlusion. He said, The occlusion or malocclusion with a variety of treatment approaches, including of the buccal teeth gives no indication of the real posi- removable appliances, partial fixed appliances, orthope- ” tion of the dentures in relation to facial outlines. dic chincup, and facemask for a short duration. Correc- tion of the anterior crossbite should be carried out as ETIOLOGY OF CLASS III MALOCCLUSION soon as it is detected to maximize the orthopedic effects Class III malocclusion can be a result of pure and the stability of early treatment.23,24 Correcting an mandibular prognathism or maxillary hypoplasia and anterior crossbite increases the maxillary arch retrognathism, or a combination of the two.
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