Managing Class 3 Malocclusions: C H A P T e R

M A N A G I N G C L A S S 3 M A L O C C L U S I O N S 3 2 5
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6
19
Chapter
Managing class 3 malocclusions

David Birnie
3 2 6 M A N A G I N G C L A S S 3 M A L O C C L U S I O N S
Introduction
Mild class 3 malocclusions can be treated in the same manner as class 1 malocclusions with the use of
some light class 3 traction to produce a class 1 buccal segment and incisor relationship.
The diagnosis and management of more severe class 3 malocclusions is however more challenging. The
treatment of class 3 malocclusions has not proved as amenable to orthopaedic management or the use of
functional appliances as have class 2 malocclusions.
This chapter explores the background to and current concepts in the management of the class 3
malocclusion.
Characteristics
Contributing Factor Percentage Range The incidence of class 3 malocclusion is variable ranging
Maxillary retrusion 19.5% to 37.5% from 4% to 14% in Chinese and Japanese studies, 4% in
Mandibular protrusion 19.1% to 45.2% Sweden and 1% in white Americans. The incidence of
Both the above 1.5% to 30% anterior crossbite in the 1993 Child Dental Health Survey in
England and Wales was 10%. Although class 3 malocclusion
Table 19.1: The composition of class 3 has often been ascribed to mandibular prognathism, a
malocclusions number of studies have demonstrated the problem to be
more complex as shown in the Table 19.1.
In a paper by Guyer, Ellis, Behrents and McNamara (1986), the components of class 3 malocclusion were
explored and is shown in Figure 19.1. In this paper, 56% of class 3 malocclusions had maxillary deficiency
as one of the components of the malocclusion.
The same paper showed that 59% of class 3 malocclusions had reduced or neutral lower facial heights and
that 41% had increased lower facial heights.
Reasons for early treatment of class 3 malocclusions

Hägg et al (2004) and Ngan (2005) cite the reasons for early treatment as:
• to eliminate CR-CO discrepancies which may cause

o progressive and irreversible soft tissue periodontal damage (normally labial to lower
incisors)
30% n=144
o progressive and
n=144
n-144 irreversible hard tissue
26%
25%
25% periodontal damage
22%
(normally labial to
20% lower incisors)
o occlusal wear as a
15%
12%
result of the anterior
crossbite
• temporomandibular joint
10% 8%
5%
4%
3%
o the joint may be more
1% susceptible to
0% dysfunction if there is a
Mn+ Mx- Mx-/Mn+ Neutral Mx+/Mn+ Mx-/Mn- Mx+ Mn- CR-CO discrepancy
o remodelling may occur
Figure 19.1: Components of class 3 malocclusions (from Guyer et al in the joint making
1986) correction of the
crossbite more difficult at a later date

• to provide a more favourable environment for growth and development of the maxilla and
mandible with a reduction in dental compensation
• to simplify later treatment and reduce the requirement for orthognathic surgery
• to correct the anterior displacement of the mandible before the eruption of the canines and
premolars so that they can be guided into a class 1 relationship
• to provide space for the eruption of the buccal segments as a result of proclination of the
upper incisor
• psychological benefits resulting from improved dental and facial appearance
Development of treatment
Pseudo class 3 malocclusions
Pseudo class 3 malocclusions are characterised by retroclination of the upper incisors and a forward
mandibular displacement on closure. A high proportion of class 3 cases are pseudo class 3 malocclusions.
Correction of anterior crossbite (Reynolds method)

Ian Reynolds (1978) described a simple way of correcting anterior cross bites which were amenable to
treatment by dental compensation. This involves the use of vertical cross elastics from the palatal of the
upper incisors to the labial of the lower incisors; TP Red elastics work well. Correction is normally
accomplished within 14 days.
4 x 2 appliance
Hägg et al (2004) have described the use of a 4 x 2 (four incisor bonds and two molar bonds/bands)
appliance with advancing loops to correct pseudo class 3 malocclusions. 75% of the cases were treated
with the 4 x 2 appliance only while 25% required a further phase of full fixed appliances. In no patients did
the negative overjet return.
Orthopaedic change in class 3 malocclusions

Dermaut and Aelbers (1996) have reviewed the possible effects of orthopaedic treatment in class 3
malocclusions. 50% of the studies looked at showed stimulation of maxillary growth and surprisingly, 90%
showed an inhibition of mandibular projection as measured by SNB. The annual change expected was
calculated as 1.8° in ANB. The changes detected are small and there is continued doubt about their
clinical relevance.
Mandibular skeletal appliances

The use of chincups was a popular treatment modality based on the belief that the mandible was the major
contributor to the class 3 malocclusion; they remain a method of treatment in Far Eastern populations.
Chincups are of two types:
• occipital pull
o used for patients with mandibular prognathism
• vertical pull
o used for patients with increased anterior face height
Normal wear is 14 hours a day and the recommended force levels are 300-500 g.
Most studies have found little difference in mandibular dimensions in patients treated with chincup therapy
compared with a control group. Chincups cause lingual tipping of the lower incisors (Thilander 1963) and
clockwise rotation of the mandible. Forces of 250g to 900g were used.
In a long-term study of chincup therapy on skeletal profile by Sugawara et al (1990), chincup therapy was
effective in reducing mandibular prognathism before puberty but this advantage was then lost. The final
skeletal profile with respect to the anteroposterior position of the mandible was no different between the
experimental and control groups. The average duration of chincup therapy in this study was 4.5 years.
Time does not seem to result in any improvement in techniques and the disappointing results of chincup
therapy are again reported in 1995 by Üner et al.
Sugawara and Mitani (1997) comment that:
• the skeletal framework of class 3 malocclusion is established before puberty

• chincup appliances greatly improve the skeletal profile in the short term
• such changes are however rarely maintained during the pubertal growth spurt
However, Deguchi and McNamara (1999) have reported that chincup therapy in class 3 malocclusions
results in the following changes:
• an increase in SNA (0.8° per year)

• a decrease in SNB (0.7° per year)
• a smaller increase in Co-Gn
This hints that chincup therapy may result in a reduction in mandibular growth. Many Asian patients have
excessive mandibular growth as part of their class 3 syndrome. Retardation and redirection of mandibular
growth and posterior repositioning of the mandible is therefore a desirable treatment strategy for class 3
malocclusions.
The effects of chincup therapy have been reported as:
• backward rotation or distal displacement of the mandible

• retardation of mandibular growth redirection of mandibular growth vertically
• remodeling of the mandible with closure of the gonial angle retardation of downward growth
and reinforcement of forward growth in the maxilla
Few, if any, UK orthodontists use chincups. Ko et al (2004) investigated cephalometric determinants of

successful chincup therapy – treatment in which a good facial profile, positive overbite and overjet, and
Class I canine and molar occlusal relationship without severe facial and dental asymmetry (less than 2
mm) where achieved at age of 17 years or later. The authors found that patients with significant
anteroposterior discrepancy, lower incisor compensation and open bite tendency had results with chincup
therapy that were not subsequently maintained. Patients were asked to wear the chincup for 12 to 14
hours per day with a force of 300 to 500 g per side during the early treatment period. The chincup force
was directed toward the mandibular condylar head from the chin. Once the anterior crossbite was
corrected, the patient was instructed to wear the chincup at least 10 hours per day until slight Class II
canine and molar relationships were established.
There is as yet no method of orthodontic treatment that has been shown to reduce effectively the size of
the mandible. If suitable camouflage of the malocclusion cannot be achieved then orthognathic surgery
should be considered.
Intermaxillary skeletal appliances

The use of intermaxillary appliances such as functional appliances (e.g.: the FR 3) has had some
popularity. For most operators the results have been disappointing. The FR 3 has no effect on maxillary
retrusion and the lip pads would seem to be of limited effectiveness. These appliances again rotate the
mandible down and back allowing the mesial and vertical eruption of the upper first molars to contribute to
the class 3 correction. They are however used by many orthodontists as a retaining appliance once
successful correction of a class 3 malocclusion has taken place with maxillary protraction.
Maxillary skeletal appliances

The technique of maxillary protraction is based on work by Nanda (1978), with young and adult rhesus
monkeys in which he showed that a force of approximately 500g could produce anterior displacement of
the maxilla. The use of maxillary protraction headgear has been popularised by Delaire and Cozzani
(1981) and is discussed later. It is worth remembering that rapid maxillary expansion also frequently
causes forward movement of the maxillary complex.
Diagnosis
Differential diagnosis of class 3 malocclusion should include the following aspects:
• social and medical history

• extraoral assessment
• cephalometric assessment
• function
• dental assessment
• growth status
Social and medical history

Many class 3 malocclusions a have a genetic basis and a familial history of significant class 3 malocclusion
is a contraindication to early orthodontic treatment. Patients with cleft lip and palate may present with class
3 malocclusions. Acromegaly is a rare but a frequently quoted medical condition resulting in class 3
malocclusion.
Extraoral assessment
A full face and profile extraoral assessment is essential. Much of this is covered in the chapter on Facial
Appearance, the Smile and Tooth Aesthetics. The zero meridian of Gonzalez-Ulloa, originally developed to
assess the likely success of genioplasty, is a good method of assessing chin position. Soft tissue
pogonion normally lies, ± 5 mm, on a vertical line through soft tissue nasion.
Cephalometric assessment
Individual cephalometric measurements often give different interpretations of diagnostic features and
treatment changes (Kelson et al 2003).
Useful cephalometric measurements:
• ANB
• Maxillary-mandibular length
o (Co-prognathion) – (Co – lower ANS)
normally 23 mm at age 12
• Wits appraisal
• SN:mandibular border length
o normally 1:1 in pseudo-class 3 cases
Stellzig-Eisenhauer et al (2002) have looked at distinguishing between those patients with class 3
malocclusions who can be treated orthodontically and those patients who require orthognathic surgery in
an attempt to further refine the work of Proffit and Ackerman and that of Kerr et al. They used discriminant
analysis to determine which cephalometric measurements would best aid the decision to treat a patient
surgically or non-surgically according to the following treatment objectives:
• stable occlusion in sagittal, transverse, and vertical dimensions

• correct overjet and overbite

• proper incisal inclination
• good facial esthetics and
• long-term stability
The authors found that the Wits analysis was the most important factor in discriminating between the
surgical and non-surgical group with the surgical group having a Wits analysis value of –12.2 ± 4.3 mm and
the non-surgical group -4.6 ± 1.7 mm. Thus the Wits analysis is another useful discriminator between
patients requiring surgical or non-surgical treatment.
Function
The type of class 3 case that it is becoming possible to treat orthodontically is that with a moderate amount
of maxillary retrusion and a decreased lower facial height. However, moderate class 3 malocclusions are
often complicated by a mandibular displacement caused by the incisor relationship. This makes it difficult
to assess the true occlusal relationships. The suggestion that the ability to achieve an edge to edge incisor
relationship is a favourable prognostic indicator for treatment with simple appliances cannot be sustained.
This is not an accurate indicator of skeletal base discrepancy as it is significantly affected by the amount of
incisor compensation.
Dental assessment
A rather more simple technique is to estimate the molar relationship (in the retruded axis position if
necessary). This should be corrected for mesial drift due to early tooth loss anterior to the first molar.
Malocclusions with molar relationships greater than ¼ of a unit class 3 should be viewed with caution.
Molar relationships less than this combined with maxillary retrusion and mild mandibular protrusion
orthodontic management of the malocclusion may be possible.
Kerr et al (1992) set out to refine Proffit’s envelopes of discrepancy that set boundaries for the limits of
orthodontic treatment in class 3 malocclusions. It was concluded that the critical factors in differentiating
patients who required surgery from those who did not were anteroposterior discrepancy (ANB = -4°;
maxillary mandibular ratio = 0.84), lower incisor inclination (LI/MP = 83°) and soft tissue profile (Holdaway
angle = 3.5°). Interestingly, vertical dimension had little influence on treatment decision.
Growth status
Much debate has been expended on the use of growth markers such as height charts, weight charts, hand
wrist radiographs, the development of secondary sexual characteristics and cervical vertebra maturation
data to identify the optimum time to start early treatment. These measures tend to have poor predictive
value but are perhaps better at showing what has already happened.
Height charts are simple to do and non-invasive. And they are routinely recommended for class 3 cases
who may possibly require orthognathic surgery.
Cervical vertebral maturation (CVM)

method
An alternative method of measuring skeletal
maturity is to examine the morphology of the
cervical vertebra. Cervical vertebra maturation data
is available from a cephalometric radiograph without
further radiation. Originally described by Lamparski
(1972), this method was modified by Hassel and
Farman (1995) (CVMI) and latterly by Baccetti et al
in 2002 (CVMS). It is worth becoming familiar with
the CVMI and slightly simpler CVMS methods as
Figure 19.2: The Cervical Vertebra Maturation (CVM)
method (after Baccetti et al 2005)
CVM stage Cervical vertebral development Peak mandibular growth
1 The lower borders of the cervical vertebrae are flat Not earlier than 1 year after this
The bodies of C3 and C4 are trapezoid with the upper surface sloping stage; on average two years after
downwards and anteriorly this stage
2 The lower borders of C2 is concave. The bodies of C3 and C4 still Within 1 year after this stage
trapezoid
3 The lower borders of C2 and C3 are concave Will occur during the year after
The bodies of C3 and C4 are either trapezoid horizontally rectangular this stage
4 The lower borders of C2, C3 and C4 are still concave Has occurred within 1 or 2 years
The bodies of C3 or C4 are horizontally rectangular before this stage
5 The lower borders of C2, C3 and C4 are still concave Ended at least 1 year before this
At least one of the bodies of C3 or C4 has now become square; if not stage
square, the body of the other vertebra is horizontally rectangular
6 The lower borders of C2, C3 and C4 are still concave. At least one of Ended at least 2 years before this
the bodies of C3 or C4 are vertically rectangular in shape; if not if not stage
vertically rectangular, the body of the other vertebra is square
Table 19.2: The Cervical Vertebral Maturation method (CVM) (from Bacetti et al 2005)
this maturational information is available from the lateral skull radiograph.
The CVMS method (which uses only C2, C3 and C4) published by Baccetti et al (2002) in 2002.
Now known as the Cervical Vertebra Maturation (CVM) method undergoes continual refinement and the
latest version is published by Baccetti et al (2005). It is shown in Figure 19.2 and described in Table 19.2.
Baccetti et al (2005) suggest that class 3 patients treated with protraction headgear and a facemask well
before the pubertal growth spurt (CS 1 or CS 2) have a different outcome to those treated at the peak of
the pubertal growth spurt (CS 3). Furthermore, prepubertal treatment is effective in both the maxilla and
the mandible whereas treatment at puberty is only effective at the mandibular level.
Growth Treatment Response Vector (GTRV) analysis

Ngan (2005) has described this as a method of determining whether a class 3 malocclusion can be treated
by camouflage or if surgical treatment will be required at a later date. It is calculated from two serial
cephalometric radiographs at least one year apart. The lines AO and BO are constructed in the same way
as for the Wits analysis on the first radiograph; the first radiograph is then superimposed on the second
using the stable structures of the cranial base. New lines AO and BO are then constructed using the
occlusal plane of the first radiograph. The GTRV is
1.2 then given by the following formula:
1
horizontal growth change of maxilla
GTRV =
GTRV ratio
0.8
horizontal growth change of mandible
0.6
0.4 The normal GTRV of patients from the Bolton

0.2 Growth Study is 0.77 – ie: mandibular growth
usually exceeds maxillary growth by 23% between
0
1 1.4 1.8 2.2 2.6 3 3.4 3 4.2 4.6 5
the ages of 8 and 16 years. In a study on 20
patients carried out by Ngan, the GTRV for a group
Change in B point per 1 mm change in A point
successfully treated with facemask therapy was
0.49 ± 0.14 with a range of 0.33 to 0.88. A second,
Figure 19.3: A graph showing the change in B point for unsuccessfully treated group, had a GTRV of 0.22 ±
each 1 mm change in A point. It can bee seen that for a GTVR of 0.10 with a range of 0.06 to 0.38. The GTRVs for
0.2, The change in B point is approximately 4 mm for every 1 mm
change in A point!
the two groups were significantly different at the 0.05 level.
The graph in Figure 19.3 shows how much change there has to be in B point for every 1 mm change in A
point. For a GTVR of 0.49 therefore, B point moves forward 2 mm for every 1 mm change in A point.
However, for a GTVR of 0.2, B point moves forward 4 mm for every 1 mm change in A point. It would
almost certainly be possible to detect this without recourse to serial cephalometric films!
Monitoring of class 3 malocclusions is extremely important as it is only in this way that a worsening skeletal
pattern can be detected. The most effective way of doing this is probably careful observation of the molar
and incisor relationship; digital photographs and careful notes in the health record are probably the most
efficient way of doing this!
Principles of treatment
If, as has been shown, that it is not possible to alter the dimensions of the mandible then the only
possibilities for the correction of class 3 malocclusions are as follows:
• dental compensation
• skeletal maxillary protrusion
• clockwise mandibular rotation to reduce the prominence of B point (by posterior vertical
extrusion) caused by downward movement of the maxilla during protraction
• a combination of the above
• (orthognathic surgery)
Turley (2002) has published an excellent review article on the management of early class 3 malocclusions
with palatal expansion and facemask therapy.
Treatment of maxillary retrusion

Intra-oral appliances and skeletal change
There are few, if any, intra-oral appliances which can effectively influence a class 3 malocclusion through
skeletal change. Possible candidates are the Frankel III, the bionator, the mandibular retractor and the two
piece corrector.
Originally described by Eganhouse in 1997, the two piece corrector works like a Clark Twin Block in
reverse (but with rather gentler ramps) and is augmented with class 3 elastics. Üçem et al (2004)
compared the effects of the two piece corrector and facemask therapy and not surprisingly found that the
two piece corrector produced more dental change and less skeletal change than the facemask therapy.
There was less increase in lower facial height with the two piece corrector than with face mask therapy,
perhaps due to some bite block effect from the wholly intraoral appliance.
Protraction headgears
The preferred treatment for skeletal maxillary retrusion is anterior movement of the maxilla using a
protraction headgear. This technique is described by McNamara (1993). Although it is suggested that this
is best done before the age of 8 years for maximum skeletal effect, there are few studies that positively
support early treatment. Sakamoto (1981) showed that better results in the treatment of class 3
malocclusions were achieved in younger age groups although the treatment methodology involved
chincups and URAs rather than maxillary protraction. In addition more favourable change was obtained
where the ANB difference was less class 3. In older children the changes are more likely to be due to
dental rather than skeletal change. Overambitious attempts to use this in patients with large ANB
differences are unlikely to be successful.
The use of maxillary protraction seeks to obtain the following treatment effects:
• elimination of a CR-CO discrepancy

• maxillary protraction
• forward movement of the maxillary dentition
• lingual tipping of the lower incisors
• vertical mandibular development
It can be seen that the movements are not limited just to maxillary protraction and it is perhaps more
appropriate to refer to this type of treatment as facemask therapy.
In order to maximise the amount of skeletal change in young children, a removable full coverage acrylic
splint is used with a protraction headgear. We have not found the need for custom chincups and forehead
pads and have routinely used a Great Lakes type headgear in a single (medium) size; the Petit style with a
single central vertical bar is also well tolerated and recent price changes have made it economically much
more attractive. Perspiration within the chin cup may be a problem and some patients have lined the chin
cup to make it more comfortable. The direction of pull should be slightly below the occlusal plane. The
force used is approximately 750g per side and the headgear is worn for at least 12 hours in every 24 hours.
It may be helpful to use light elastics while the patient becomes accustomed to the appliance. The acrylic
splint should have clasps on the first molars and auxiliary clasps on the primary molars together with a
Southend clasp anteriorly. There is full acrylic coverage of the occlusal and incisal surfaces of the teeth
(Proffit 1986).
McNamara (1987) has described the use of a Biocryl and wire splint that is bonded in the mouth. The
splint material should be at least 3 mm thick with a 0.045" stainless steel wire framework. The two halves
of the splint are joined by an expansion screw. Traction hooks to receive the elastics from the headgear
are placed in the first premolar region. Sarver and Johnston (1989) have described the addition of a
buccal loop which extends over the occlusal surface and which is used to make removal of the splint
easier. The bonded expander is however difficult to keep clean and most patients develop significant
reversible gingival disease at the time of removal.
An alternative design is to use upper first molar bands and bonded rests on the first deciduous molars with
a wire skeleton (similar to a Pendex appliance) and a Superscrew. This is easy to fit and robust; the rests
should approach from the distal of the deciduous first molars thus allowing hooks for the protraction head
gear to run mesially.
Ishii et al (1987) describe the effects of providing the protraction force from the first molars or the premolar
region. Protraction from the first molars results in more anterior movement and a forward and upward
rotation of the maxilla; protraction from the premolars results in less forward movement but less tendency
to upward and forward rotation.
A meta-analysis of the effectiveness of protraction facemask therapy has been published by Kim et al
(1999). Many of the articles are discussed in this chapter. They concluded that protraction headgear was
less effective in patients older than 10 years of age. Patients who did not have palatal expansion had
longer treatment times and ended up with more upper incisor proclination - i.e.: more dental change and
less skeletal change. The technique however still needs considerable evaluation in order to optimise its
application.
Franchi et al (2004) concluded that it was possible to achieve a 2 mm advancement of the maxilla that
would withstand the active growth period if RME and protraction head gear was undertaken in the
deciduous dentition or early mixed dentition. It is suggested that later treatment results only in a restriction
of mandibular growth and that at whatever age treatment takes place, correction is due to adaptations in
the skeletal bases rather than dentoalveolar movement.
Clinical summary
• maxillary protraction is best carried out before the age of 8 years
• it is facilitated by rapid maxillary expansion
• a significant amount of maxillary protraction may be lost during subsequent growth
• overall gains may be modest but nevertheless worthwhile
Palatal expansion associated with maxillary protraction

Mode of action
The associated use of palatal expansion in conjunction with protraction headgear has been advocated.
The type of expansion used is rapid maxillary expansion seeks to exploit two effects:
• the forward movement of the maxillary complex which often accompanies maxillary
expansion
• the sutural loosening which occurs during maxillary expansion which may extend upward the
age range in which a significant skeletal effect may be observed
Baik (1995) carried out an interesting study which sought to answer the following questions:
• does age influence the success of maxillary protraction?

• does rapid maxillary expansion, either prior to or concurrent with, maxillary protraction
influence the amount of protraction obtained?
The appliances used were a labiolingual appliance and a banded RME device with a Delaire type
protraction headgear used with 300g to 500g of force. The RME regime is not described.
The results were as follows:
• the sample ranged in age between 8 and 13 years. Age had no significant effect on the
amount of maxillary protraction although older children obtained less protraction
• rapid maxillary expansion increased the amount of protraction significantly (measured at A
point) by about 1 mm. Concurrent RME resulted in a nonsignificant increase in protraction
and a significant decrease in the angle between the X-axis (taken as 6° below the SN line)
and the palatal plane. This therefore means that PNS dropped down more in the group that
had RME during protraction.
Sung and Baik (1998) confirmed the independence of age on treatment effect. This study achieved a
change in ANB of 2.5° during treatment which relapsed by 0.5° posttreatment.
The rapid maxillary expansion screw may be turned a quarter of a turn either once or twice a day.
Types of screw
HYRAX
Perhaps the most popular type of screw, this reliable and easy to incorporate into an appliance. The more
recent longer plastic handled keys eliminate any danger of the patient swallowing the key.
SUPERSCREW
The ORTHOdesign Superscrew is an updated version of the Hyrax screw with added refinements including
a nylon friction washer, the use of a spanner rather than a conventional “key”, a scale which indicates the
amount of expansion already completed and an “end of screw threads” warning. It is capable of expanding
by at least 18 mm of expansion and produces 2 mm of expansion for every 1 mm of screw length. Be

careful to instruct the laboratory to insert the screw in accordance with the patient instructions for operating
it - there is no arrow on the screw to indicate which way it opens! Otherwise, this screw is a potentially
worthwhile advance and is now our preferred type of expansion screw. It is described by Klapper (1995) in
the Journal of Clinical Orthodontics.
Case selection
This technique is best suited to patients with:
• deep overbites
• antero-posterior and vertical maxillary deficiency
• normal to mildly prognathic mandibular dimensions
Franchi et al (1997) studied class 3 patients treated with functional appliances to try and determine
predictive variables for the of class 3 treatment. They found that patients having wider mandibular arches
(measured from study models), a more upward and forward inclination of the mandibular condyle in relation
to the cranial base, and an increased maxillary planes angle had unsatisfactory long-term treatment
outcomes.
Tahmina et al (2000) concluded that for chincup treatment, patients with large gonial angles, large nasion-
A point-pogonion and a large ramus plane to sella-nasion plane had less stable results than those with
smaller values. In addition, the degree of inclination of the ramus to the corpus of the mandible, and the
degree of mandibular protrusion, were key factors in determining the long-term outcome of chincup therapy
in growing class 3 patients.
Zentner et al (2001) suggested the sizes of the apical bases for the maxilla and the mandible, along with
the gonial angle and mandibular ramus and body dimensions, were the discriminating factors between
good and poor responders to early class 3 treatment an investigation using conventional appliances.
Baccetti et al (2004) attempted to develop a predictive model that could identify good or bad responders to
early orthopedic treatment of class 3 malocclusion with maxillary expansion and protraction. Good
responders were predicted by the equation:
0.282(Co −Goi ) + 0.205( Ba −T −SBL ) + 0.12( ML −SBL ) − 29.784 < 0.4065
where:
• Co is condylion
• Goi is the gonial intersection of the ramal plane and the mandibular plane
• Ba is basion
• T is the superior point of the anterior wall of the sella turcica and the tuberculum sella
• the SBL (stable basicranial line) runs through T and tangent to the lamina cribrosa of the
ethmoid
• ML is the mandibular plane
Baccetti et al (2004) therefore found that the three most useful predictive cephalometric values were:
• the length of the mandibular ramus Co-Goi

• the angulation of the cranial base Ba-T-SBL
• the angulation of the mandibular plane to the cranial base
This study used the same sample material as Franchi et al (2004) which included the following key
inclusion criteria:
• white European-American ancestry

• class 3 malocclusion at the time of the first observation characterized by an anterior
crossbite or edge-to-edge incisal relationship and a Wits appraisal of -1.5 mm or less
• no permanent teeth congenitally missing or extracted before or during treatment
The outcome of class 3 cases is therefore dependent on the relative anteroposterior position of the maxilla
and mandible and their relative size and morphology as determined anteroposteriorly, transversely and
vertically.
Ghiz et al (2005) several cephalometric measurements to try and find a predictive modle for class 3
malocclusion in a similar manner to Baccetti et al (2004). Ghiz used the following formula:
1
P=
1+ Exp( −L )
where
• P is the probability that early treatment will be successful

• L = 30.557+0.196(Co-GD)-0.129(Co-Pog)+0.162(Co-Goi)-0.206(Ar-Goi-Me)
and
• Co is condylion
• GD is the Great Divide
o a line drawn through sella at right angles to sella horizontal
• Pog is pogonion
• Goi is the gonial intersection
• Ar is articulare
• Me is menton
Ghiz et al (2005) claim that this model successfully predicts successful cases 95% of the time and
unsuccessful cases 70% of the time.
These types of prediction model tend to be better at predicting successful cases rather than unsuccessful
cases – which is the opposite way round to what orthodontists would prefer! Both the predictive equations
discussed here place a negative (prognostically unfavourable) weighting on:
• an acute cranial base angle

o the glenoid fossa is situated further forward in the face
• an increased mandibular plane angle
• increased mandibular length
Baccetti et al (2004) considered that long mandibular ramal length (increased posterior face height) was an
adverse factor while Ghiz et al (2005) believed small ramal length an adverse factor.
What age?
In determining what age is best to start treatment, it is helpful to consider:
• chronologic age
• stage of dental development
• skeletal age
CHRONOLOGIC AGE
Merwin et al (1997) compared the effectiveness of protraction headgear and maxillary expansion in class 3
patients before and after the age of 8 years. One group had an average age of 6.8 years and the other
10.2 years. The appliances consisted of a Hyrax screw to stainless steel bands and a Tubinger style
protraction headgear. A similar skeletal response was seen in both groups of patients suggesting that the
need to start treatment before the age of 8 years is not necessarily correct (compare with Baik 1995 in
paragraph above). Note that no patients were older than 12 years and orthopaedic results should not be
expected in post-pubertal children.
Kapust et al (1998) compared the effects of facemask expansion therapy in three age groups (4-7 years, 7-
10 years and 10-14 years). Generally, more treatment change occurred in the younger groups than in the
older groups. This represented an approximately 4 degree change in ANB for the combined groups
compared with the control; this change was contributed to by a slightly greater increase in SNA than a
decrease in SNB. Baccetti et al (1998) compared early treatment (6 years 9 months at T1) and a later
treatment group (10 years 3 months at T1). Patients were treated with a bonded maxillary expander and a
Petit type protraction headgear. The early treatment group showed effective forward displacement of the
maxillary structures whereas the late treatment group showed no change compared with controls.
Although both early and late facemask treatment reduced mandibular protrusion, significantly smaller
increments in total mandibular length associated with more upward and forward direction of condylar
growth were recorded only in the early treatment group.
Saadia et al (2000) found similar results in a study of 112 patients divided into 3 age groups. Younger
patients achieved greater treatment change with less appliance wear.
Yüksel et al (2001) carried out a small study which compared early (mean age 9 years 8 months) and late
treatment (mean age 12 years 6 months) groups with a control (mean age 9 years 5 months). Treatment
took, on average, 7 months and patients were treated with a Delaire type facemask and an upper
removable appliance. Both treatment groups demonstrated significant forward movement of the maxilla,
the upper incisors and the upper molars. There was a downward and backward movement of the mandible
and the mandibular dentition. Although no differences were found between the two treatment groups, the
authors concluded that the improvement in facial aesthetics produced psychosocial advantages that
favoured early treatment.
There is a concensus that the best results with protraction headgear are obtained if treatment is completed
by the age of eight years.
STAGE OF DENTAL DEVELOPMENT
Baccetti and Tollaro (1998) retrospectively compared the effect of a functional appliance (removable
mandibular retractor) on class 3 malocclusions in the deciduous and mixed dentitions. The group treated
in the deciduous dentition showed more significant skeletal change than the group treated in the mixed
dentition; these changes resulted in a more upward and forward direction of condylar growth and hence
reduced mandibular protrusion and total mandibular length. The mixed dentition group showed greater
dentoalveolar rather than skeletal change.
Baccetti, Franchi and McNamara (2000) compared the skeletal response to a bonded acrylic-splint
expander and protraction headgear in a retrospective study. There was an early mixed dentition group
(incisors and first molars erupting, mean age 7 years at the start of treatment) and a late mixed dentition
group (canines and premolars erupting, mean age 8 years 8 months at the start of treatment). Records
were available at the end of active treatment (7 years 9 months, 9 years 7 months) and post treatment (8
years 10 months, 10 years 9 months). A significant increase in sagittal growth of the maxilla (A-vertT)
occurred only in the early mixed dentition group. The late mixed dentition group encountered a backward
rotation of the mandible with corresponding increase in lower facial height. The class 3 growth pattern was
re-established in the post-treatment year although no skeletally based retention appliance (e.g.: FR 3,
chincup etc.) was used. A significant relapse tendency affected the maxillary change in the early mixed
dentition group and the sagittal position of the mandible in the late mixed dentition group.
SKELETAL AGE
Suda et al (2000) suggested that evaluating bone age would assist in determining the optimum age for
protraction treatment. These workers compared two groups of 30 patients (palatal arch, chincup,
protraction headgear and palatal arch and/or chincup) which were subdivided into younger and older
groups. The younger boys showed greater maxillary advancement than older boys and there was a
greater increase in SNA in boys who were less skeletally mature.
In 2003, Cha investigated the effects of rapid maxillary expansion and protraction headgear in three
different maturational groups as defined by Fishman’s skeletal maturity indicators (SMI) and based on hand
wrist radiographs. He divided his study into three groups, increasing growth velocity (SMI 1-3, mean age
9.8 years), peak growth velocity (SMI 4-7, mean age 11.3 years) and decreasing growth velocity (SMI 9-11,
mean age 13.1 years). There was no difference in maxillary skeletal advancement in the first two groups
but less skeletal advancement and more dentoalveolar compensation in the decreasing growth velocity
group.
How much?
Realistically, one can probably expect a 1° positive change in SNA, a corresponding negative change in
SNB and therefore a positive change of approximately 2° in ANB. The change in SNB obviously
represents a change in position rather than a change in dimension. Nartallo-Turley and Turley (1998) have
demonstrated changes of + 2.35° in SNA and 3.66° in ANB as well as linear changes of approximately 3
mm in A point and ANS. The mean age at the start of treatment was 7.26 years and treatment lasted
11.05 months. The maxillary molar and incisor moved forward 1.7 mm and 1.75 mm respectively which is
similar to that found by Ngan et al (1996).
There is usually a statistically significant increase in vertical face height due to downward and backward
rotation of the mandible (Silva et al 1998).
Franchi et al (2004) carried out a postpubertal assessment of treatment timing for maxillary expansion and
protraction headgear. In their criteria for admission to the study, the patients had to have a Wits appraisal
of – 1.5 mm or less.
Compare this with the results obtained by Stellzig-Eisenhauer et al (2002) which suggested that patients
with Wits values of -4.6 ± 1.7 mm were probably manageable with orthodontic treatment.
Stability of facemask treatment

The stability of facemask therapy is open to question. At the moment, it would seem that following the
cessation of active treatment, class 3 patients revert to a class 3 pattern of growth with deficient maxillary
growth. The growth pattern does not become normalised. This supports the need for overcorrection
during active treatment and the need for additional facemask therapy during the phase 2 stage of
treatment.
Shanker et al (1996) carried out a similar study on Chinese children but who all had maxillary expansion
with a Hyrax screw. In this study there was a statistically significant forward movement of “A” point of 2.4
mm compared with 0.2 mm in the control group. In the year after treatment, the change in “A” point
between the two groups was similar and no relapse occurred in the treatment group.
Chong et al (1996) compared the posttreatment growth of 16 patients treated with facemasks and
labiolingual appliances or bonded palatal expanders with 13 untreated matched class 3 controls over a
period of 3.6 years. No difference was found between the treated patients and the class 3 controls during
the post-treatment observation period, although reduction in overjet occurred in the treated group.
Gallagher et al (1998) have shown that in late treatment group, there is considerable relapse post-
treatment (ANB pre-treatment = -0.3°, ANB post-treatment = 1.1°, ANB at follow-up = 0.3°).
Ngan et al (1998) looked at maxillary expansion and protraction in a Chinese population treated at 8.4
years of age. In this study, RME was only carried out for 7 days before protraction compared with the more
usual 10-14 days. Changes of 1.6° were found in SNA and 3.0° in ANB during treatment although some
relapse occurred in the two-year period after treatment (-0.3° and -2.0° respectively). Substantial amounts
of relapse were found in the upper arch expansion but not in the mandibular arch; RME did not result in a
net increase in arch perimeter. The study did not continue into puberty when it might be expected that
further relapse might occur.
MacDonald et al (1999) compared the posttreatment growth of a treated class 3 sample with a class 3 and
a class 1 sample over 2.3 years. When the untreated class 1 and class 3 samples were compared, the
class 3 group had less maxillary growth and greater forward mandibular growth. After treatment, the
treated class 3 group reverted to a class 3 type of growth.
Finally, Hägg et al (2003) carried out a long term follow up of patients who had been treated with rapid
maxillary expansion and reverse pull headgear. The average age of the patients at the start of treatment
was 8.7 years and the average treatment time 0.8 years; all patients had a positive overjet at the end of
treatment. After a follow-up period of 8.2 years, only two thirds of the patients had positive overjet. In the
patients that relapsed, mandibular growth was four times that in the maxilla. So potentially, this type of
treatment has a 33% failure rate and probability of orthognathic surgery as a final treatment solution.
Fitting
The splint is fitted by etching the buccal and palatal surfaces of the upper posterior segment teeth only (to
ease removal). The appliance is then bonded in place using a slow setting acrylic adhesive such as Excel
(Reliance). The patient is asked to bite on cotton wool rolls to fully seat the splint. Excess adhesive can be
removed with a scaler or bur (when fully set). It is easier to sit the patient upright to fit the appliance as this
prevents slow setting acrylic from running out of the back of the splint.
The screw can be turned 0.25-0.5 mm per day (rapid expansion) or 1 mm per week (slow expansion) as
suggested by Proffit (1986).
The headgear or facemask is given to the patient two weeks after the start of maxillary expansion to allow
some sutural loosening to take place. McNamara suggests full-time wear of the facemask but this is
impractical for most patients. The direction of pull should be slightly below the occlusal plane. The wear of
the mask is continued until a positive overjet of 2-5 mm is obtained. The result is then stabilised for 3-6
months with occasional night time wear of the facemask. A removable retainer is worn after the splint and
facemask are removed.
Sarver (1989) investigated the difference in effect between banded RME appliances and bonded
appliances with biteblocks. This study did not involve the use of protraction headgear but simply the
correction of posterior crossbites. The biteblocks were 2-3 mm in height. Sarver found that the use of
biteblocks was associated with:
• a slight superior movement of PNS

• inferior and posterior movement of ANS
• inferior and posterior movement of the upper incisors
and therefore less likely to lead to a decrease in overbite than the use of a banded appliance. However,
Reed et al (1999) concluded that there were no clinical differences in the amount of inferior movement of
the palatal plane between patients treated with bonded and banded appliances and that patients with high
mandibular plane inclinations did not exhibit greater vertical change than those with lower inclinations.
Overall, there is perhaps little to choose between the two methods.
Ngan et al (1996) showed that significant dentoskeletal changes and improvements in dentofacial profile
could be obtained from 6 months treatment with maxillary expansion and protraction.
Velázquez et al (1996) hypothesised that the adverse effects of RME were dissipated by normal growth in
the years post treatment.
This is supported by Chang et al (1997) who investigated the hypotheses that RME opens the bite and also
moves the maxilla downward and forward. The study defined bite opening as an increase in anterior facial
height or opening of the maxillary mandibular planes angle or both. It compared an RME group (Haas type
appliance), being treated for transverse maxillary deficiency, a standard edgewise group and a control
group. The study found no evidence to support the suggestion that RME caused bite opening or that it
caused forward and downward movement of the maxilla. However, the study only included class 1 and
class 2 cases and may not be applicable to class 3 cases.
Patrick Turley (1996) offers the following advice:
• use a rigid expansion appliance to expand the maxilla

• 24 hour wear of the protraction headgear using a custom appliance
• avoid camouflaging movements such as:
o proclination of the maxillary incisors to correct crowding or an anterior crossbite
o avoid lower incisor retroclination
o and hence avoid class 3 elastics for as long as possible
• overcorrect to an end on canine relationship
• retain with night time only protraction headgear for a further three to six months until there is
good posterior interdigitation and a positive overbite
• monitor
• reinstate protraction headgear during phase 2 treatment
An interesting paper from Seattle has been published by Chong et al (1996). This compared the treatment
effects and post treatment changes following maxillary protraction in 16 patients compared with 13
matched and untreated control subjects. The age at the start of treatment ranged from 4.58 to 8.25 years.
Palatal expansion was only carried out in three patients who had pre-existing crossbites. Protraction
treatment was discontinued when a positive overjet or flush postlactal plane was achieved. Treatment
resulted in significant changes in ANB and the overjet; although the treated subjects showed an increase in
SNA, this was not statistically significant. The major reason for the improvement in the overjet was
downward and backward rotation of the mandible. There may be some temporary growth retardation at the
condyles as the mandibular length increased less in the treated patients than in the controls. Improvement
in the overjet was less marked at the time of follow-up; despite this a positive overjet was maintained at the
end of follow-up in the patients. The treatment was considered unsuccessful however if the overjet was
less than 2 mm; 5 out of the 16 cases fell into this category.
Ngan et al (1997) suggested that:
• correction of class 3 malocclusion was achievable in 6-9 months and was stable 2 years
after appliance removal
• maxillary expansion in conjunction with protraction produced greater forward movement of
the maxilla
• significant and beneficial soft tissue profile change can be expected during treatment
• treatment works best in patients with retrusive maxillas and hypodivergent growth patterns
The treatment effects of maxillary protraction with or without rapid expansion therefore require further study
before we have a clear idea of the treatment effects. Vaughn et al (2001) carried out a prospective
randomised control trial to determine whether rapid maxillary expansion enhanced the amount of maxillary
protraction. Two groups were used: one treated with facemasks and active palatal expansion, the other
with facemasks and passive expansion appliances. The results of this study showed no differences
between the expansion and the nonexpansion groups in any cephalometric variable, in overall treatment
time, or in the time for initial crossbite correction. The authors argue that, without other reasons for
expansion, such as maxillary width or space deficiency, expansion does not significantly aid in Class 3
correction.
This study was further reported by Vaughn et al (2005). The authors concluded that significant and similar
changes in ANB (up to almost 4 degrees) and the Wits appraisal (up to almost 4 mm) could be obtained
from the use of protraction facemasks with or without RME. The study was only continued up to the end of
treatment and no report of what happened during and post-retention is included.
Williams et al (1997) have quantified the amount of change that takes place with protraction and RME and
compared it with figure for normal growth (Riolo). Protraction and RME have a small skeletal effect and a
moderate dentoalveolar effect.
Labial root torque

Most class 3 patients demonstrate considerable proclination of the upper labial segment at the end of
treatment. Although we have not tried it much, the use of labial root torque (achievable by inverting the
upper incisor brackets) with advancement of the upper labial segment is food for thought. The case
published by Catania et al (1990) demonstrates significant maxillary development with only mild to
moderate proclination of the incisors using this technique.
The problems of anterior open bites

In patients with a class 3 malocclusion and an increased lower facial height, problems may arise using this
approach because as the maxilla is protracted it also moves downward decreasing the overbite. Every
attempt must be made to prevent downward growth of the maxilla and posterior tooth eruption.
In many cases, successful management of this type of case will require orthognathic surgery.
Phase 2 treatment
It is sensible to wait for the second molars to erupt before starting phase 2 treatment to allow evaluation of
post phase 1 growth and to minimise the length of fixed appliance treatment. Males seem to show greater
adverse growth in class 3 cases in the teenage years than females. This is probably because males show
more latent mandibular growth than females. Björk and Helm (1967) showed that condylar growth may
continue for up to two years after cessation of growth in physical height. Males show greater condylar
growth than females and this growth occurs in a more forward direction which may contribute to the
tendency for adverse growth during the second decade.
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Managing Class 3 Malocclusions: C H A P T e R

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M A N A G I N G C L A S S 3 M A L O C C L U S I O N S 3 2 5

Managing class 3 malocclusions

Reasons for early treatment of class 3 malocclusions

• to eliminate CR-CO discrepancies which may cause

crossbite more difficult at a later date

Correction of anterior crossbite (Reynolds method)

Orthopaedic change in class 3 malocclusions

Mandibular skeletal appliances

Sugawara and Mitani (1997) comment that:

• the skeletal framework of class 3 malocclusion is established before puberty

• an increase in SNA (0.8° per year)

The effects of chincup therapy have been reported as:

• backward rotation or distal displacement of the mandible

Few, if any, UK orthodontists use chincups. Ko et al (2004) investigated cephalometric determinants of

Intermaxillary skeletal appliances

Maxillary skeletal appliances

• social and medical history

Social and medical history

Useful cephalometric measurements:

• stable occlusion in sagittal, transverse, and vertical dimensions

• correct overjet and overbite

Cervical vertebral maturation (CVM)

CVM stage Cervical vertebral development Peak mandibular growth

this maturational information is available from the lateral skull radiograph.

Growth Treatment Response Vector (GTRV) analysis

0.4 The normal GTRV of patients from the Bolton

the two groups were significantly different at the 0.05 level.

Treatment of maxillary retrusion

• elimination of a CR-CO discrepancy

Palatal expansion associated with maxillary protraction

• does age influence the success of maxillary protraction?

The results were as follows:

by at least 18 mm of expansion and produces 2 mm of expansion for every 1 mm of screw length. Be

0.282(Co −Goi ) + 0.205( Ba −T −SBL ) + 0.12( ML −SBL ) − 29.784 < 0.4065

• the length of the mandibular ramus Co-Goi

• white European-American ancestry

• P is the probability that early treatment will be successful

• an acute cranial base angle

STAGE OF DENTAL DEVELOPMENT

Stability of facemask treatment

• a slight superior movement of PNS

Patrick Turley (1996) offers the following advice:

• use a rigid expansion appliance to expand the maxilla

Ngan et al (1997) suggested that:

Labial root torque

The problems of anterior open bites

Baccetti T, Franchi L and McNamara JA (2005)

Hägg U, Tse A, Bendeus M and Rabie ABM (2004)

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