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UIP HEALTH MED., 2016, 1(1)
doi: http://dx.doi.org/10.7454/uiphm.v1i0.13
Treatment of Class III Malocclusion in an Adolescent with Banded
RPE/Face Mask and Self-Ligating System
Dwita Pratiwi*, Benny Mulyono Soegiharto
Department of Orthodontics, Faculty of Dentistry, Universitas Indonesia, Jakarta 10430, Indonesia
*
E-mail: [email protected]
Abstract
This case report describes the treatment of a 12-years-old female with a Class III skeletal profile and dental
malocclusion. The clinical examination showed concave profile, class III dental relationship, buccal crossbite on
the right side, and mild crowding. The cervical vertebral maturation analysis showed the patient was on the CS3
stage. The class III malocclusion was treated with combination of banded rapid palatal expander and face mask
followed by non-extraction orthodontic treatment with self-ligating system. Banded rapid palatal expander and
face mask were used to improve the skeletal discrepancy. Class I maxilla-mandibular relationship was achieved
along with class I molar, incisor, and canine relationship. The buccal crossbite and mild crowding were corrected,
the overbite and overjet were normal, and the facial profile was improved. This case demonstrates a good result
of a class III malocclusion treatment in an adolescent patient with banded rapid palatal expander/face mask and
self-ligating system.
Keywords: adolescent, class III, face mask, rapid palatal expander, self-ligating
protraction is effective in both jaws when is
performed before the peak, whereas is only
effective in the mandible during the pre-pubertal
and pubertal stage.14 Meanwhile Yavuz et al15 in
their research concluded that forward displacement
of maxilla and clockwise rotation of the mandible
occurred in both adolescent and young adults. This
case report demonstrates the orthodontic correction
of a class III malocclusion using a banded RPE and
FM in an adolescent patient.
Introduction
Class III malocclusion is one of the most difficult
cases in orthodontics. The prevalence of this
malocclusion in South East Asia reaches to 15.8%
of the population.1,2 It may occur as a result of
skeletal and dental discrepancies and could lead to
aesthetic and functional impairment.3 Patients with
this malocclusion could have maxilla retrognathism,
mandibular prognathism, or combination of both,
reverse over jet, anterior and buccal crossbites,
proclination of upper incisors, and retroclination of
lower incisors.4,5 The treatment plans of class III
malocclusion were determined by the age of the
patient and the severity of the cases. In growing
patient, orthopedic correction through growth
modification has proven to be success, and it
reduced the need of orthognathic surgery at later
age. Meanwhile in adult patient, the options are
camouflage treatment or orthognathic surgery for
severe cases.6-10
Case Report
Diagnosis
A 12 years old girl came to Clinic of Orthodontics,
Faculty of Dentistry, Universitas Indonesia with her
mother who concerned about her forward
appearance of the mandible. On extra oral
examination, the patient had concave profile and
mesocephalic head (Figure 1). On intraoral
examination, she had an anterior crossbite in
relation to all incisors, class III molar relationship,
class III canine relationship, buccal crossbite on the
right side, mild crowding in upper and lower arch,
reverse over jet of 1 mm, and overbite 2 mm (Figure
2).
Growth modification using the combination of face
mask and rapid palatal expander has become a
standard protocol in the early management of class
III malocclusion. This treatment produces the
forward movement of the maxilla and clockwise
rotation of the mandible which could lead to better
facial profile of the patient.7,11-13 Bacetti et al (2005)
stated that class III treatment with expansion and
1
Figure 3. Lateral cephalogram before treatment
Figure 1. Facial photographs before treatment
Figure 4. Panoramic film before treatment
Table 1.
Cephalometric analysis before, after
FM/RPE & final results
Skeletal
Normal
Parameters
SNA
82° ± 2°
SNB
80° ± 2°
ANB
2° ± 2°
The Wits
0±2
Facial Angle 87° ± 3°
Angle of
Convexity 0° -10°
Y-axis
60° ± 6°
Go angle
123° ± 7°
SN-MP
32° ± 3°
MMPA
27°± 5°
Facial axis 90°± 3.5°
UAFH:
LAFH
45:55
Dental Parameters
Interincisal
Angle
130° ± 3°
UIMaxPlane
109° ± 6°
UI-NA
4 mm ± 2
UI-Apg
4 mm ± 2
LI-Apg
2 mm ± 2
LI-MP
90° ± 4°
LI-NB
4 mm ±2
Figure 2. Intraoral photographs before treatment
From the cephalometric evaluation, patient had a
skeletal class III base with prognathic maxilla and
mandible (SNA = 86º and SNB = 88º). Maxillary
incisors were proclined relative to the maxilla plane
(UI-Mx = 123º) and mandibular incisors were
retroclined relative to the mandibular plane (LI-MP
= 85º). The lower anterior facial height was short
(UAFH: LAFH = 52:59) and normal vertical growth
pattern (Facial axis = 88º). Regarding the soft
tissues, her upper lip was retrusive relative to the Eline and positioned behind the lower lip. Patient was
still growing and from the cervical vertebral
maturation analysis, patient was in CS3 stage
(Figure 3 and Table 1). From the panoramic
evaluation, there was no sign of pathological
condition, no missing teeth and the roots of the teeth
were not parallel (Figure 4).
86°
88°
-2°
-12 mm
91°
88°
87°
1
-5 mm
89°
Final
Result
88°
87°
2
+1 mm
89°
-3°
61°
138°
33°
27°
88°
2°
62°
140°
36°
32°
89°
3°
62°
141°
37°
33°
90°
52: 59
52:65
52:66
126°
125°
132°
123°
6 mm
4 mm
7 mm
85°
6 mm
124°
5 mm
5 mm
5 mm
80°
7 mm
114°
6 mm
6 mm
4 mm
78°
6 mm
-3 mm
0 mm
-1 mm
0 mm
-2 mm
-1 mm
Before
Post FM/RPE
Soft Tissue Parameters
Upper Lip- E line -4 mm
Lower Lip-E line -2 mm
2
Treatment Objectives
The treatment objectives were: (1) To improve the
skeletal jaw relationship by protracting the maxilla
anteriorly in relation to the cranium; (2) To achieve
well-aligned teeth in maxillary and mandibular
arches with class I incisor, canine, and molar
relationship; (3) To correct the buccal crossbite by
expanding the maxilla; (4) To obtain ideal overjet
and overbite; (5) To obtain ideal aesthetic and
function.
Treatment Plan
The treatment was divided into two phases. The
first phase was to protract the maxilla using a
facemask while simultaneously expanding it using
RPE. The RPE disrupts the intermaxillary suture
and thus promotes maxillary protraction. The
treatment was followed by fixed orthodontic
appliance using self-ligating system to level and
align the teeth, correction of incisors, canine, and
molar relationship.
Treatment Progress
Treatment was started with banded RPE which had
hooks incorporated on the buccal side between the
permanent canine and first premolar. This appliance
was activated for 1 turn/day (0.25 mm) for 8 days. It
was stated before that even in patients who do not
need any maxillary expansion; RPE should be
activated for 8-10 days prior to facemask
placement.6,7,12 After 8 days, petit type face mask
therapy was begun. Posterior bite blocks were built
in permanent mandibular first molars. Extra oral
elastic was placed from the hook of the RPE to the
face mask bar to obtain forward and downward
traction in the maxilla. Patient was instructed to use
the FM and TigerTM elastics (3/8”, 8oz) for 15
hours/day minimum 12. The approximate duration
of wear as reported by the patient’s mother 1 month
later was only 8-10 hours. After 6 months of phase
one treatment, the overjet was edge to edge and the
face mask therapy was stopped (Figure 5 and 6).
The fixed orthodontic treatment was started with
CuNiti .014 archwires in the upper and lower jaw.
Posterior bite blocks were built in the permanent
mandibular first molars to open the occlusion, and
the patient was instructed to wear the class III
elastics (CliffTM; ¼”, 3.5oz). Space closure was
done using 0.019 x 0.025 stainless steel (SS)
archwire. Settling of occlusion was done with 0.019
x 0.025 SS wire in upper and lower arch and
vertical settling elastics in posterior. Retention was
given with essix retainer in the upper arch and fixed
retainer in the lower arch.
Figure 5. Facial
treatment
Figure 6. Intraoral
treatment
photographs
photographs
after
after
FM/RPE
FM/RPE
Treatment Results
The patient exhibited excellent profile after
RPE/FM treatment. There were significant changes
in the maxillomandibular relationship (ANB = 1º)
and lower anterior facial height increased as
3
observed from the lateral cephalogram (Figure 7
and 8). After 18 months of fixed orthodontic
appliance treatment, the patient’s smile became
more aesthetic. The teeth in the upper and lower
arches were aligned and leveled, the incisors,
canines, and molar relationships were corrected into
class I (Figure 9 and 10). The cephalometric
analysis indicated that the lower facial height was
increased and the inclination of upper incisors was
normal. However, the inclination of lower incisors
was still retroclined (Figure 11 and 12). Total
duration of active treatment including face mask
and fixed appliance was 24 months.
Figure 9. Facial photographs after fixed appliance
treatment
Figure 7. Lateral
treatment
cephalogram
after
FM/RPE
Figure 8. Panoramic film after FM/RPE treatment
Figure 10. Intraoral
appliance treatment
4
photographs
after
fixed
treatment can provide a viable option for older
children. This result supported by Yavuz et al 15
who stated that the forward movement of maxilla
and clockwise rotation of the mandible was seen in
both groups, adolescent and young adults. After 6
months of the FM/RPE treatment, this patient
showed the skeletal improvement on both jaws.
Similar to the study by Podesser et al,19 Lione et
al,20 and Tanaka et al,21 the RPE in this patient
succeeded to correct the buccal crossbite on the
right side by expanding the maxilla. After the RPE
treatment, there was overcorrection. It was then
corrected and finished by the fixed appliance, so the
patient has normal posterior over jet by the end of
the treatment. The fixed orthodontic appliance
treatment was done with self-ligating system. The
bracket in this system has mechanical door so it
does not need elastomer or ligature wire. This
design allowed the wire to move freely inside the
slot so the friction between the bracket’s slots and
wire is low and the tooth movement would be more
efficient.22,23 Harradine24 in his research stated that
treatment with self-ligating system could be
finished in 4 months faster and 4 visits lesser than
conventional system.
Figure 11. Lateral cephalogram after fixed appliance
treatment
Posterior bite block was built in the permanent
mandibular first molar to open the occlusion and
relieve the tension from the facial muscles. This
allowed the wire to work optimally and the teeth
would be positioned in their neutral zone. The
patient was instructed to use class III early elastic.
The combination of posterior bite blocks and early
light elastics made it possible to improve the sagittal
and vertical relationship since the beginning of the
treatment.25,2 After 3 months of fixed appliance
treatment, the reverse over jet of this patient were
corrected and the molar relationship became class I.
At the finishing stage, we instructed patient to use
vertical settling elastic to correct the open bite on
the buccal side. This technique caused the lower
anterior facial height increased which improved the
facial profile. The stability of the treatment could be
influenced by the incisors relationship, growth
pattern, interdigitation of the teeth, muscle’s
tension, and the severity of the case. In this patient,
we achieved the class I incisors relationship and
good interdigitation. We also instructed the patient
to use the retainer to maintain the result of the
treatment.
Figure 12. Panoramic film after fixed appliance
treatment
Discussion
The skeletal jaw relationship in this patient was
corrected through the orthopedic treatment of the
class III malocclusion by using the FM and RPE.
The skeletal effects were seen in both jaws. There
was a forward and slightly downward movement of
the maxilla as a result of the protractive force. As
the consequence of this, the mandible rotated
downward and backward, thus resulting class I
skeletal relationship in this patient.16-18 This effect
also caused the lower anterior facial height
increased. Since the patient had short lower facial
height, this effect was advantageous. Other effects
were shown in the changes of Go angle, MMPA,
SN-MP, angle of convexity, and the wits (Table 1).
Treatment timing in class III malocclusion is an
important thing to consider especially when dealing
with growing patient. The skeletal maturation of the
patient needs to be analyzed before we decided to
do the growth modification treatment. Baccetti et al
13
stated that the use of FM/RPE would be optimum
on both jaw in patient with CS 1 and CS 2 stage,
meanwhile in older patients, the skeletal effect only
shown in the mandible.14 However, another research
by Kapust et al 18 showed that although early
treatment may be the most effective, FM/RPE
Conclusion
This case report shows that class III skeletal
malocclusion in adolescent can be successfully
managed using the combination of FM and RPE
procedure followed by fixed orthodontic treatment
with self-ligating system.
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14. Baccetti T, Franchi L, McNamara JA. The Cervical
Vertebral Maturation (CVM) Method for the
Assessment of Optimal Treatment Timing in
Dentofacial
Orthopedics.
Semin
Orthod
2005;11:119-129.
15. Yavuz I, Halicioglu K, Ceylan I. Face mask Therapy
Effects in Two Skeletal Maturation Groups Female
Subjects with Skeletal Class III Malocclusions.
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16. Ngan P. Treatment of Class Malocclusion in the
Primary and Mixed Dentitions. In: Bishara SE,
editor. Textbook Of Orthodontics. Philadelphia: W.B
Saunders; 2001. p. 375-414.
17. Williams MD, Sarver DM, Sadowsky PL, Bradley E.
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