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Volume 31 Issue 1 Article 6

2020

The Orthodontic Treatment of Class III with Anterior Cross Bite and Severe Deep Bite

Chieh Yang School of , College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of , Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Yu-Chuan Tseng School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, [email protected]

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Recommended Citation Yang, Chieh and Tseng, Yu-Chuan (2020) "The Orthodontic Treatment of Class III Malocclusion with Anterior Cross Bite and Severe Deep Bite," Taiwanese Journal of Orthodontics: Vol. 31 : Iss. 1 , Article 6. DOI: 10.30036/TJO.201903_31(1).0006 Available at: https://www.tjo.org.tw/tjo/vol31/iss1/6

This Case Report is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of Orthodontics. Case Report

The Orthodontic Treatment of Class III Malocclusion with Anterior Cross bite and Severe Deep bite

Chieh Yang, Yu-Chuan Tseng School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

This 22-year-old female presents with skeletal Class III malocclusion, complicated by anterior cross bite, deep bite, and congenital missing of bilateral mandibular second premolars. The treatment modality was full- mouth fixed edgewise appliances. A favorable result of ideal and and closure of bilateral spaces of missing teeth were achieved. The patient was satisfied the improvement of function and esthetics after treatment. (Taiwanese Journal of Orthodontics. 31(1): 53-63, 2019)

Keywords: pseudo-Class III malocclusion; anterior cross bite; deep bite; congenital missing.

As for anterior cross bite, except some patients are INTRODUCTION truly skeletal Class III malocclusion, some others are For correction of skeletal Class III malocclusion, pseudo-Class III malocclusion. These pseudo-Class III Proffit states that there are three treatment options: 1) patients may present some characteristics as: 1) normal growth modification, use differential growth of the or mildly larger size of ; 2) normal or mildly relative to the mandible; 2) camouflage of the skeletal smaller size of maxilla; 3) incisors could be guided to discrepancy through tooth movements to correct the edge-to-edge in resting position; 4) difference between dental while maintain the skeletal discrepancy; centric occlusion (CO) and centric relation (CR); 5) first 1 or 3) orthognathic surgical correction. The treatment molars may occlude in Angle’s Class III relationship. option is depending on the patient’s age, the facial The profiles of pseudo-Class III patients usually are profile, the skeletal pattern, the alveolar bone reaction concave, upper lips are less prominent due to insufficient on mandibular incisors, and the severity of malocclusion support of upper incisors, while soft tissue menton and before treatment. lower lips are more protrusive, but these Class III profiles

Received: September 11, 2018 Revised: March 16, 2019 Accepted: March 31, 2019 Reprints and correspondence to: Dr. Yu-Chuan Tseng, Department of Orthodontics, Kaohsiung Medical University Hospital, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan. Tel: +886-7-3121101 ext 7009 Fax: +886-7-3221510 E-mail: [email protected]

Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 1 53 10.30036/TJO.201903_31(1).0006 Yang C, Tseng YC are much improved in rest position while incisors are The extraoral examination revealed that the patient in edge to edge position. Anterior has been had skeletal Class III malocclusion with midface associated with a variety of complications, such as deficiency, mandibular , acceptable lower gingival recession of the lower incisors, incisal edge wear, facial height, insufficient display of upper incisors while and eventually lost of these teeth. Correction of anterior smiling (Figure 1). crossbite could enhance the oral health and achieve The intraoral examination revealed that the patient better occlusion. The aim of this article is to present the had Angle’s Class III malocclusion with anterior crossbite treatment of a pseudo-Class III malocclusion in an adult and deep bite with an accentuated curve of Spee in patient complicated by deep bite and congenital teeth the lower arch and supra-eruption of lower incisors. missing. The dental spaces in the lower arch resulted from the congenital missing of bilateral lower second premolars (Figures 1, 2). Besides, this patient was a pseudo-Class CASE REPORT III malocclusion since her mandible could be guided to A 22-year-old female patient who had no history incisors edge to edge position (Figures 3, 4). The initial of illness or trauma, presented the following complaints revealed that this patient was including anterior crossbite and mandibular protrusion. skeletal Class III malocclusion with normal mandibular The dental spaces in the lower arch came from congenital plane angle, retroclined upper and lower incisors and tooth missing. retrusive upper lip (Figures 5, Table 1).

Figure 1. Extraoral and intraoral photographs, before treatment.

54 Taiwanese ournal of Orthodontics. 2019, Vol. 31. No. 1 10.30036/TO.20190331(1).0006 Anterior Cross Bite with Deep OB

Figure 2. Study models, before treatment.

Figure 3. Intraoral photographs before treatment. The mandible could be guided to edge to edge bite.

Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 1 55 10.30036/TJO.201903_31(1).0006 Yang C, Tseng YC

A B

Figure 4. The lateral facial profile in: A , centric occlusion; B , edge-to-edge incisal contact.

A B

Figure 5. A , lateral cephalometric film; B , before treatment.

Table 1. Cephalometric measurements before and after treatment.

Measurement Pre-tx Post-tx Normal Range

SNA 79.0 80.0 79.8 ~ 83.2 SNB 80.0 78.5 75.7 ~ 78.7 ANB -1.0 1.5 3.2 ~ 5.0 SN-MP 36.0 38.0 33.8 ~ 38.4 U1 to NA mm 4.0 7.5 4.3 ~ 8.1 U1 to SN° 92.0 104.5 103.85 ~ 108.75 U1 to NB mm 7.5 6.0 5.4 ~ 10.2 U1 to MP° 78.0 77.0 93.4 ~ 99.2 E-line: Upper -3.5 -0.5 0.7 ~ 3.1 E-line: Lower 0.0 0.0 0.1 ~ 3.4

56 Taiwanese ournal of Orthodontics. 2019, Vol. 31. No. 1 10.30036/TO.20190331(1).0006 Anterior Cross Bite with Deep OB

Diagnosis also used to correct the anterior crossbite and rotate the ● Skeletal Class III relation mandible in clockwise direction. Thus, mild mandibular ● Orthodivergent facial pattern protrusive posture was improved by the Class III ● Angle’s Class III malocclusion mechanics.

● Anterior crossbite and deep bite Treatment progress ● Congenital missing of #35, 45 Orthodontic treatment was carried out by using

Treatment objective the pre-adjusted 0.022-inch slot self-ligation system,

● and lower anterior resin bite blocks were also added in To correct the anterior crossbite and deep bite, achieve the initial stage to disocclude the bite and facilitate the normal overbite and overjet by upper anterior teeth correction of anterior crossbite (Figure 6). It took about proclination and lower anterior teeth retraction. seven months to accomplish the leveling and alignment ● To improve the facial profile and lip posture. and correct the anterior crossbite. Reposition of some ● To close the mandibular dental space. brackets to calibrate the position and root angulation after Treatment plan mid-term panoramic film taking. Continuing the crossbite No further tooth extraction was planned for this correction and closing the residual mandibular spaces patient. Full-mouth fixed edgewise appliances were were accomplished in another nine months. After a total bonded for leveling and alignment in the upper and lower treatment duration of 32 months, the upper wraparound dentition. The mandibular space was closed by lower and the lower fixed retainer were used for anterior retraction and . Class III elastic was retention (Table 2).

Figure 6. Full mouth bonded with fixed appliance with light wire leveling and bite block in the lower anterior teeth.

Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 1 57 10.30036/TJO.201903_31(1).0006 Yang C, Tseng YC

Table 2. Summary of treatment progress.

Upper Lower

• Bonding • Bonding • Leveling and alignment • Leveling and alignment 103 / 11 ~ 104 / 06 • Crossbite correction • Crossbite correction - short Class III - short Class III elastics

104 / 06 ~ 105 / 03 • Keeping crossbite correction • Spaces closure

105 / 03 ~ 105 / 10 • Releveling • Releveling and Keeping flattening curve of Spee

105 / 10 ~ 106 / 07 • Finishing and detailing • Finishing and detailing

• Debonding • Debonding 106 / 07 - wraparound retainer - 34-44 fixed retainer

Treatment results second premolars. Canine relation was finished in Class The facial profile maintained in mild concave at I relationship by lower anterior retraction and Class III midface (Figure 7). Normal overbite and overjet, Class elastics. The superimposition of cephalometric tracings I canine relationships as well as coincident facial and revealed that the upper incisors were proclined, and the dental midlines were achieved (Figure 8). The molar upper lip also became more prominent after treatment. relation was finished in bilateral Class III due to the dental In addition, the upper first molar was mesialized; lower space closure of congenital missing mandibular bilateral incisors were retracted and intruded while lower first

Figure 7. The facial and intraoral photographs, after treatment.

58 Taiwanese ournal of Orthodontics. 2019, Vol. 31. No. 1 10.30036/TO.20190331(1).0006 Anterior Cross Bite with Deep OB molar was mesialized and extruded; and the mandible to mandibular plane angle (SN-MP) also increased from showed clockwise rotation (Figure 9, 10). The root 36° to 38°. The distance between upper incisor to NA line parallelism and root resorption were acceptable and within increased from 4 mm to 7.5 mm, and the angle between the normal range (Figure 11). The cephalometric analysis upper incisor to SN plane increased from 92° to 104.5°. comparing the initial and final conditions indicted that The lip posture was improved by increase the distance of the ANB angle increased from -1° to 1.5°, the SN line upper lip to E-line from -3.5 mm to -0.5 mm (Table 1).

Figure 8. The study models, after treatment.

Figure 9. Superimposition of cephalometric tracings. Black line, before treatment; red line, after treatment.

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A B

Figure 10. Regional superimposition of cephalometric tracings. A , maxilla; B , mandible; black line, before treatment; red line, after treatment.

A

B

Figure 11. A , lateral cephalometric film; B , panoramic radiograph, after treatment.

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fixed appliances with Class III elastics and bondable resin DISCUSSION bites for disocclusion was effective to correct the anterior For correction for skeletal Class III malocclusion, crossbite. The anterior resin bites also help to intrude the there are three main treatment options: growth supra-eruptive lower anterior teeth. The upper teeth show modification, orthodontic camouflage therapy, and was insufficient before treatment. By flaring of upper surgical-orthodontics. Growth modification by dentofacial anterior incisors, the crowding in upper dentition was orthopedic appliances is an effective method to resolve relived and the pleasing smile curve was also achieved. 2-5 skeletal Class III jaw discrepancies in children. Proffit The patient’s upper lip rests on the gingiva margin of indicated the criteria of case selection to enhance the upper incisors when smile. The tooth show exceeds the outcome of orthodontic camouflage therapy, including: (1) proposed minimum of 0 to 2 mm of upper lip coverage average or short facial pattern; (2) mild anteroposterior of the anterior teeth for posed smile in Asian female 11 jaw discrepancy; (3) crowding less than 4-6 mm; (4) standard. normal soft tissue features (nose, lips, chin); (5) no In treating anterior crossbite with camouflage transverse skeletal problem. Tseng et al. used the receiver orthodontic treatment, lingual tipping of lower anterior operating characteristic analysis of cephalometric teeth may result in wash-board appearance and periodontal variables to distinguish the skeletal Class III damage. The cephalometric analysis indicated the change who requiring . There of lower incisor inclination was few ( L1-MP: 78° to 77°). should meat 4 of these 6 measurements that indicated for The reasons for the few change in the lower incisors may surgical treatment: (1) overjet, ≦ –4.73 mm; (2) Wits be attributed to: (1) light force and short distance of Class appraisal, ≦ –11.18 mm; (3) L1-MP angle, ≦ 80.8°; III elastics (3/16” 2 oz) were applied when small-sized (4) Mx/Mn ratio, ≦ 65.9%; (5) overbite, ≦ –0.18 mm; initial working NiTi wires (0.013 / 0.014 inch) were used 6 and (6) gonial angle, ≧120.8°. For this patient, only to avoid unwanted side effect of over-retraction in lower 2 of these 6 measurements (L1-MP angle=79°; gonial anterior teeth; (2) gradually increase the size of working angle=122°) met the surgical indication. Besides, this wires with appropriate amount of buccal crown torque in patient had average facial pattern, mild anteroposterior lower anterior teeth when closing lower dental space; (3) jaw discrepancy with upper dentition crowding, no the combination of pre-torque NiTi wire (.017 x .025 NiTi transverse skeletal problem; patient’s incisors could be with 20 degree lingual root torque) for torque control of shifted to edge to edge position with relative normal lower anterior teeth. soft tissue features in this position; so, this patient was The mandibular second premolars are the most arranged for camouflage orthodontic treatment. frequent congenitally missing teeth followed by 12 For correction of the anterior crossbite, disoccluding mandibular and maxillary lateral incisors. The etiology the bite for unrestricted pathway in the initial tooth of tooth agenesis is considered to involve the disturbance movement is essential. Various treatment methods have of dental development by genetic factors, environmental been proposed to correct anterior dental crossbite, such factors, or combination of both. Many researchers have as tongue blades, reversed stainless steel crowns, fixed reported that tooth size is often smaller in patients with 13-18 acrylic planes, bonded resin-composite slopes and tooth agenesis than in patients without tooth agenesis. 7-10 removable acrylic appliances with finger springs. The Two treatment approaches are available to solve the aforementioned appliances might be huge, uncomfortable, missing tooth space: (1) close the spacings and allow the and only applicable in young patients. For adult patients, permanent first molar drift mesially and then complete

Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 1 61 10.30036/TJO.201903_31(1).0006 Yang C, Tseng YC the space closure orthodontically; (2) retain or regain between skeletal or dental Class III malocclusion. The 19 the spaces for prothesis. As for this patient, the dental factors in identifying the patient as dental or skeletal Class spacings were small (< 3mm) and the lower anterior III malocclusion and the factors in achieving good results teeth retraction was required for the cross bite correction, of camouflage treatment were reviewed. The patient with the space was closed for camouflage treatment and no dental Class III malocclusion can be well treated with further prosthesis. To finish in Class III molar occlusion, proper evaluation and camouflage treatment. the occlusion should be evaluated for the existence of mandibular third molars to make sure that there REFERENCE are antagonist teeth to occlude the maxillary second 1. Proffit WR. Contemporary Orthodontics. 5th Ed. St. molars. Some adjustment might be required to occlude Louis, MO, Elsevier Mosby, 2013. the mandibular first molars with maxillary premolars in 2. Chang HP, Lin HC, Liu PH, Chang CH. Geometric finishing a good Class III molar relationship, including morphometric assessment of treatment effects positioning the mandibular first molars lingually than of maxillary protraction combined with chin cup normal; no offset in ; more offset in appliance on the maxillofacial complex. J Oral the maxillary premolars and molars; no toe-in in maxillary Rehabil 2005;32:720-8. molars; lingual crown torque in mandibular molars; 3. Chang HP, Liu PH, Chang HF, Chang CH. Thin-plate reduced palatal crown torque in maxillary premolars and spline (TPS) graphical analysis of the mandible on molars. Some contouring or occlusal adjustment was cephalometric radiographs. Dentomaxillofac Radiol required for better intercuspation, such as reduction of the 2002;31:137-41. palatal cusps in the maxillary premolars and molars or 4. Chang ZC, Chang HP, Chen YJ, Yao CC, Liu PH, the augmentation of the buccal cusps of the mandibular .20 Chang HF. The treatment effects of the face mask molars with restoration therapy in the midfacial configurations in skeletal When reviewing the long treatment duration (32M) Class III growing patients by means of morphometric for this patient, the main time was spent on correction of techniques. J Formosa Med Assoc 2005;104:935-41. anterior crossbite. The length to use the lower anterior 5. Lin HC, Chang HP, Chang HF. Treatment effects of resin bite blocks was not long enough, so the patient occipito-mental appliance of maxillary still could move the mandible forward as the upper protraction combined with chincup traction in children anterior teeth were still locked within the lower anterior with Class III malocclusion. J Formosa Med Assoc teeth while biting or eating. The anterior crossbite was 2007;106:380-91. further corrected after the use of .017 x .025 pre-torque 6. Tseng YC, Pan CY, Chou ST, Liao CY, Lai ST, NiTi (20-degree, buccal crown torque) combined short Chen CM, Chang HP, Yang YH. Treatment of Class III elastics. When remove the resin bite block, the adult Class III malocclusions with orthodontic mandible position should be re-evaluated and confirmed therapy or orthognathic surgery: receiver operating for stability. characteristic analysis. Am J Orthod Dentofac Orthop 2011;139:e485-e493. CONCLUSION 7. Olsen CB. Anterior cross bite correction in Class III malocclusion may be a difficult task in uncooperative or disabled children. Case reports. Aust orthodontic treatment, since we need to differentiate Dent J 1996;2013:304–9.

62 Taiwanese ournal of Orthodontics. 2019, Vol. 31. No. 1 10.30036/TO.20190331(1).0006 Anterior Cross Bite with Deep OB

8. Valentine F, Howitt JW. Implications of early anterior 19. Jha P, Jha M. Management of congenitally missing cross bite correction. J Dent Child 1970;2013:420–7. second premolars in a growing child. J Conserv Dent 9. Deam JA, McDonald RE, Avery DR. Managing the 2012;15:187-190. developing occlusion. In: McDonald RE, editor., ed. 20. Farret MMB, Farret MM, Farret AM. Strategies to Dentistry for the child and adolescent. 7th ed London: finish orthodontic treatment with a Class III molar Mosby, 2000;677–741. relationship: three patient reports. World J Orthod 10. Vadiakas G, Viazis AD. Anterior crossbite correction 2009;10:323-333. in the early deciduous dentition. Am J Orthod Dentofac Orthop 1992;2013:160–2. 11. Ioi H, Kang S, Shimomura T, Kim SS, Park SB, Son WS, Takahashi I. Effects of vertical positions of anterior teeth on smile esthetics in Japanese and Korean orthodontists and orthodontic Patients. J Esthet Restor Dent 2013;25:274-282. 12. Higashihori N, Takada JI, Katayanagi M, Takashi Y, Moriyama K. Frequency of missing teeth and reduction of mesiodistal tooth width in Japanese patients with tooth agenesis. Prog Orthod 2018;19:30. 13. Baum BJ, Cohen MM. Agenesis and tooth size in the permanent dentition. Angle Orthod 1971;41(2):100–2. 14. Brook AH, Griffin RC, Smith RN, Townsend GC, Kaur G, Davis GR, et al. Tooth size patterns in patients with and supernumerary teeth. Arch Oral Biol 2009;54(Suppl 1):S63–70. 15. Garn SM, Lewis AB. The gradient and the pattern of crown-size reduction in simple hypodontia. Angle Orthod 1970;40:51–8. 16. Gungor AY, Turkkahraman H. Tooth sizes in nonsyndromic hypodontia patients. Angle Orthod 2013;83:16–21. 17. McKeown HF, Robinson DL, Elcock C, al-Sharood M, Brook AH. Tooth dimensions in hypodontia patients, their unaffected relatives and a control group measured by a new image analysis system. Eur J Orthod. 2002;24(2):131–41. 18. Schalk-van der Weide Y, Steen WH, Beemer FA, Bosman F. Reductions in size and left-right asymmetry of teeth in human oligodontia. Arch Oral Biol 1994;39(11):935–9.

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