ISSN 0103-6440

Brazilian Dental Journal (2013) 24(2): 167-173

http://dx.doi.org/10.1590/0103-6440201301588

Early Treatment Protocol for

Skeletal Class III Malocclusion
Paula Vanessa Pedron Oltramari-Navarro1, Renato Rodrigues de Almeida1,
Ana Cludia de Castro Ferreira Conti1, Ricardo de Lima Navarro2, Marcio
Rodrigues de Almeida1, Leandra SantAnna Ferreira Parron Fernandes1

Skeletal Class III malocclusion, with its unpredictable and unfavorable nature, has been
characterized by a growth pattern with doubtful prognosis regarding orthodontic mechanics,
even when performed early. For a long time, Class III malocclusion was regarded as a synonym
of mandibular prognathism, regardless of the affected skeletal structures. Mandibular growth,
essentially determined by genetic factors, could barely be controlled by early orthodontic
interventions. Therefore, the treatment choice was to wait for the patient to grow, and
then make an orthodontic intervention associated with an orthognathic surgery. Maxillary
involvement in the etiology of Class III malocclusion was conclusive to change orthodontic
therapeutics. Maxillary intramembranous growth has a better response to orthopedic treatment,
based on growth control and redirection, thus contributing for early intervention success.
In several cases, excellent results have been achieved with rapid maxillary expansion and
protraction. The aim of this study was to describe and discuss the treatment of a patient
with Class III malocclusion, whose treatment planning comprised two phases: interceptive
(mechanical orthopedic appliances) and comprehensive (fixed orthodontic appliance). The
results of this case showed that Class III malocclusion should be intercepted as early as
possible to permit growth redirection, mainly when the maxilla is the primary etiologic factor
or dental and/or functional factors are involved. Diagnosis, treatment planning and prognosis
depend on patient age, growth potential and severity of malocclusion. Early intervention,
adequate indication of appliances, and patient compliance are key factors for good outcomes.

Introduction

Noticeable characteristics of Class III malocclusion result

in unpleasant aesthetics for a child, and consequently lead
parents to seek for orthodontic treatment at an early age.
The negative dentoskeletal discrepancy between the apical
bases, at the sagittal dimension, is mainly verified by a
concave profile caused by deficiency of the facial middle
third, absence of a zygomatic prominence and excess of the
facial lower third. These features can also be accompanied
by maxillary atresia, lower lip protrusion, and/or an anterior
crossbite (1,2).
This malocclusion has been characterized by skeletal,
functional, and dental discrepancies, which may or may
not be associated with each other. In the facial evaluation,
mandibular prognathism, maxillary retrognathism or
both can be observed, characterizing a skeletal Class III
malocclusion (3,4). Maxilla and mandible may assume
different relationships in sagittal and vertical directions.
Maxillary deficiency has been regarded as the primary
etiologic factor of this malocclusion development, and also
a decisive feature for a good prognosis (5-7).
Considering the functional aspect, the presence of
an anterior crossbite may be observed as a result of a
mandibular forward displacement, due to abnormal occlusal
contact. In cases of tooth crossbite, an axial inclination
involvement of the maxillary and/or mandibular teeth

1Department

of Orthodontics,
UNOPAR - University of North
Paran, Londrina, PR, Brazil
2Department of Dentistry, Area of Oral
and Maxillofacial Surgery, Graduate
Program, UNESP - State University
of Maring, Maring, PR, Brazil
Correspondence: Profa. Dra. Paula
Vanessa Pedron Oltramari-Navarro,
Rua Paranagu, 803, ap. 92, Centro,
86020-030 Londrina, PR, Brasil.
Tel: +55-43-3371-7991. e-mail:
pvoltramari@hotmail.com

Key Words: orthodontic

interceptive, malocclusion,
Angle Class III, palatal
expansion technique.

can be observed (3). Consequently, in a dental or functional

crossbite without skeletal involvement, the diagnosis and
treatment should also receive special attention, to avoid
skeletal structure implications (8).
After skeletal disharmony is confirmed, a differential
clinical diagnosis of Class III malocclusion should be made,
and the occlusal pattern both at Centric Relation (CR)
and Intercuspal Position (IP) should be verified (Fig. 1).
This evaluation affords the severity of the malocclusion,
and distingushes the functional (caused by a mandibular
forward displacement) from a skeletal or dental Class III
malocclusion. Lateral cephalograms, at the aforementioned
occlusal positions, confirm this diagnosis (Fig. 1) (3,9).
Other relevant aspects concerning the diagnosis should
also be taken into account, such as: family history, growth
potential and pattern, in addition to the patients age (3,10).
A thorough evaluation in transversal, sagittal, and vertical
directions is essential.
Considering a skeletal Class III malocclusion, the greater
the maxillary involvement at the expense of participation of
the mandible, the better the prognosis. In this condition, the
orthopedic treatment to be performed aims at redirecting
patient growth by applying forces on sutural surfaces. This
treatment protocol results in forward displacement of the
maxilla and in bone apposition. Accordingly, significant
sagittal changes are induced, thus allowing a non-surgical

Braz Dent J 24(2) 2013

correction of the malocclusion in several cases (6,11-13).

The observation of clinical reports (5,13) has indicated the
advantages of an early treatment, performed at early mixed
dentition. It is important to note that, in order to achieve
a good outcome, the treatment should be started before
the pubertal growth spurt, taking great advantage of its
potential. Furthermore, it should be taken into account
that the end of the maxilla growth preceeds the growth
of the mandible.
The aim of this study was to describe and discuss the
treatment of a patient with Class III malocclusion, whose
treatment protocol comprised two phases: interceptive
(mechanical orthopedic appliances) and comprehensive
(fixed orthodontic appliance).

Case Report

mesial relationship of the primary molar and canines

and an anterior crossbite, thus characterizing a Class III
malocclusion.
At CR, an edge-to-edge incisor relationship was
observed, which improved the prognosis (Fig. 1D).
Radiographic examination was performed aiming to
complement the clinical examination for establish the
diagnosis. A panoramic radiograph showed the presence
of all permanent teeth either already erupted or at the
several stages of formation, in mixed dentition.
The lateral cephalogram evaluation at IP afforded
detection of a Class III malocclusion and an acute ANB angle.
In cases where the mandible has an anterior deviation, it is
essential to take a lateral cephalogram at CR, so that the
low severity of the malocclusion may be ascertained and
greatly favor treatment prospects.

P.V.P. Oltramari-Navarro et al.

Diagnosis and Etiology

A nine-year-and-10-month-old female patient sought
orthodontic treatment with chief complaint of an anterior
crossbite. During the anamnesis, a good general health
condition was observed without deleterious oral habits.
Facial evaluation showed lack of middle third development
(Fig. 1A and 1B). In the intraoral examination, at IP (Fig.
1C), the patient showed anterior mandibular displacement,

Treatment Options and Expected Results

There are several appliances for early treatment of
skeletal Class III, such as, Bionator (14), Frankel (FR-III) (15),
chincup (16,17), Reverse Twin-Block (RTB) (18,19), Eschler
appliance (progenic appliance) (16) and protraction face
mask treatment (20). These appliances treatment results
depend on patients compliance. Initially, the Eschlers

Figure 1. A and B: Initial extraoral photographs. C: Initial intraoral photographs at intercuspal position. D: Centric relation.
168

Braz Dent J 24(2) 2013

retention clasps, e.g. Adams clasp for molars, and intermolar

auxiliary clasps for deciduous teeth and premolars, b)
Eschlers labial bow, made in 0.9-mm stainless steel wire
and adapted at the labial surface of the lower incisors, c)
Case Description
occlusal lifting in acrylic resin with a thickness of about 2
In this clinical case, the treatment protocol comprised
to 3 mm. If necessary, springs can be added to correct the
two phases: an interceptive phase and a comprehensive
anterior crossbite, and an expander screw, to correct the
phase.
posterior crossbite.
The interceptive phase started immediately after the
The patient used the appliance for 10 months, with
clinical and radiographic evaluation, with a removable
poor compliance, especially regarding the expander screw
orthopedic appliance: Eschlers appliance, the so-called
activation. Notwithstanding, significant improvement of
Progenic Appliance. This appliance is composed of: a)
the anterior crossbite was observed at IP (Fig. 2A). However,
an adequate correction of the posterior crossbite
and improvement of the facial profile were still
necessary.
Accordingly, rapid maxillary expansion (RME)
was performed, followed by maxillary protraction
(2,4,5,9,10,13,14). Besides correcting the posterior
crossbite, RME stimulates sutural cellular activity,
enhancing protraction results (3,6,15). This can
be performed by using a Hyrax-type expander,
composed of buccal hooks soldered onto the
appliance to receive the protraction elastics (Fig.
2B and 2D). The expander screw was activated
following Haas protocol (1961), and consisted of
one full turn (4/4 1 mm) just after the appliance
installation, followed by daily activations of 2/4
turn (1/4 in the morning and 1/4 in the evening
mm), which lasted for some 2 weeks. On the
14th day of activation, a facemask for maxillary
protraction was installed (Fig. 2C).
Maxillary protraction was carried out during the
active phase of RME, and the face mask was used
during 14 hours per day. A large array of extraoral
appliances for maxillary protraction is available.
In this case, Turleys face mask was chosen, which
requires an impression of the patients face with
alginate. Then a cast of the patients face was
obtained at a laboratory to build an individual
appliance. Half-inch (1/2) elastics were applied,
and changed every two days, with forces of 500
g, on each side.
After 8 months of active treatment, the overjet
was overcorrected, and the face mask was only
used as a night retention appliance. In this phase,
aiming at increasing the patients comfort, the
expander appliance was changed to a fixed palatal
Figure 2. A: Intraoral photographs showing pre-expansion aspect. B: Hyrax-type
bar, extending up to the premolars, on both sides.
expander. C: Extraoral photograph showing the maxillary protraction face mask. D:
Thus, retention was maintained in the arch posterior
Intraoral photograph previous to the reverse traction of the maxilla. E: Extraoral
aspect after the active phase of the maxillary protraction. F: Superimposition of
area, allowing the use of the face mask for other
the lateral cephalogram tracings at the beginning of the treatment (black) and
8 months. Additionally, a Nance lingual arch was
after the reverse traction of the maxilla (red). G: Intraoral photograph showing
installed on the lower arch as a space maintainer,
the comprehensive phase.
169

Early treatment for skeletal Class III malocclusion

appliance was chosen in this case, followed by the facemask

protocol considering the maxillary deficiency compounding
the Class III malocclusion (20).

P.V.P. Oltramari-Navarro et al.

Braz Dent J 24(2) 2013

and kept until the complete development of permanent

dentition.
After the use of the maxillary protraction mask (Fig.
2E and 2F), an anterior displacement of the maxilla was
verified due to the increase of SNA and NperpA. Also, a
mandibular clockwise rotation was obtained, attested
by an increase of SNGoGN and a reduction of SNB, both
contributing to increase facial convexity (ANB, NAP), and
to improve the facial profile.
The comprehensive phase started after completion of
the interceptive phase, and was carried out when the dental
arches were at the stage of complete permanent dentition.
This stage aimed at treatment finalization. Thus, the arches
were both aligned and leveled (Fig. 2G), followed by the
use of: Class III elastics on the right side; Class II elastics
on the left side; and two elastics crossed in the anterior
area, in order to distribute the forces to correct the dental
midline. A quarter-of-an-inch (1/4) diameter elastics were
used in this phase, and changed every three days.
After 20 months of comprehensive treatment, a
satisfactory functional occlusion was achieved, and the
facial profile obtained in the interceptive phase was
maintained (Fig. 3A-3C). Initial and final cephalometric
measurements, at IP, also demonstrated good treatment
outcomes (Table 1).
Three years after the end of comprehensive treatment,
the 17-year-old patient came to a follow-up appointment,
and stability of the results was ascertained (Fig. 3D-3F).

Discussion

Although most studies have been based on cephalometric

values, which are insufficient to define reliable normality
methods and parameters, it is possible to state that real
mandibular prognathism is less frequent than originally
thought. Consequently, Class III therapy and treatment
prognosis become more favorable (6).
Cephalometric values should be carefully analyzed, since
Class III malocclusion patients have an acute cranial base
angle and lower cranial base length. Also, a more posterior
N point is observed. Accordingly, the measurements using
the cranial base as reference (SNA, Nperp-A, SNB, Nperp-B)
cannot be evaluated individually. Ideally, the real length of
both the maxilla and mandible should be assessed (Co-A,
Co-Gn), at each age (20).
Additionally, the use of normative patterns of one agegroup for subjects at another age-group may negatively
affect diagnosis and treatment planning (10). Therefore,
when only SNA and SNB measurements are used, the
mandible is considered as the main contributing factor
for the malocclusion (6).
In Class III patients, a lateral cephalogram at CR is
extremely important for the diagnosis, because it shows
real maxillary and mandibular involvement. When a lateral
cephalogram, taken at CR, is observed (Fig. 1F), good
possibilities of success of the treatment can be verified
due to the edge-to-edge relationship of the incisors. This
was observed in the present study, since the cephalometric

Figure 3. Final extraoral (A and B) and intraoral (C) aspects. Three-year post-treatment follow-up: extraoral (D and E) and intraoral photographs (F).
170

measurements at CR demonstrated real maxillary and

mandibular participation (Table 1). Consequently, the
prognosis improved, when compared with that evaluated
with the use of a lateral cephalogram at IP (Fig. 1E), which
had shown greater mandibular involvement (3).
In the facial analysis, the patient showed an anterior
shift of the mandible, with ANB and NAP involvement,
which contributed to form a concave facial profile. The
NPerp-P value confirmed this finding, and the reduced
ALFH reinforced the appearance of protrusion. SNGoGn
and SNGn angles confirmed the anterior lower mandibular
growth. Co-A and Co-Gn values showed the maxilla in a
more retrusive condition (Table 1).
This cephalometric analysis allowed establishing
the treatment protocol comprising maxillary expansion
and protraction. The lateral cephalogram image showed
the proportion of maxillary involvement in the Class III
malocclusion, thus affording a good prognosis (3,6).
Following the maxillary expansion and protraction,
the initial (Fig. 1E) and post-protraction (Fig. 2G) lateral
cephalograms at IP were superimposed, and centered at SN.
Improvement of the post-protraction measurements could
be clearly noted (Table 1). The changes of the ANB and NAP
values resulted in a better profile, and in a more anterior
position of point A, also confirmed by the positive value

of Nperp-A. The increase of ALFH reduced the appearance

of mandibular prognathism, and the changes in SN-GoGN,
SN-Gn and Co-A values confirmed growth redirection.
The changes normally observed after maxillary
expansion and protraction have been the anterior
displacement of the maxilla, with an increase of the SNA
angle, and an improvement of Nperp-A. This was possible
due to the anterior shift of point A, and to the mandibular
clockwise rotation, with retropositioning of point B (11,21).
The counterclockwise rotation of the maxilla occurs
due to the palatine plane rotation in relation to the cranial
base, which contributes to increase the facial convexity and
profile improvement (ANB-NAP). Additionally, a backward
and downward rotation of the mandible occurs, resulting
in changes of the SNGn and ALFH values. Considering the
ALFH values, patients with increased facial height previous
to the maxillary disjunction will very likely show a more
evident value. The magnitude, duration, and direction of the
protraction significantly influence the rotation center of
the maxilla. It has been recommended that the protraction
force be horizontal, parallel to the occlusal plane, or
slightly directed downward and forward, resulting in an
angle of 20 to 30 in relation to the occlusal plane. As a
result, the effect of the palatine plane rotation is reduced
(7,12,17,18). The retroclination of the mandibular incisors

Table 1. Comparison of pre- and post-expansion/protraction measurements

Cephalometric
variables

Pattern value
10 years

Initial
(Centric relation)

Initial (Intercuspal
position)

Post-expansion/Protraction
(Intercuspal position)

Pattern value
12 years

SNA ()

81.5

87.8

88.0

90.8

81.1

SNB ()

78.2

88.3

90.1

88.9

78.9

ANB ()

3.3

-0.5

-2.1

2.0

2.2

NAP ()

6.1

0.0

-3.4

1.2

2.5

SN.GoGn ()

34.1

26.5

24.5

23.1

33.2

SN.Gn ()

77.3

61.4

59.3

61.0

78.5

Co-A (mm)

83.9

74.5

72.1

77.9

86.9

Co-Gn (mm)

106.4

102.1

99.2

106.0

113.7

Nperp-A (mm)

-1.3

1.1

0.3

5.9

-1.1

Nperp-P (mm)

-7.9

2.3

3.2

9.2

-4.5

1.NA ()

24.2

28.9

32.5

20.7

26.1

1-NA (mm)

3.7

4.4

5.3

3.1

4.6

1.NB ()

27.6

24.6

23.9

17.0

26.8

1-NB (mm)

4.7

4.0

4.1

2.8

4.7

ALFH (mm)

61.9

56.1

53.0

57.9

64.2

IMPA ()

92.5

86.8

86.7

81.2

92.4

-7.3

-7.9

-4.1

Witts (mm)

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Early treatment for skeletal Class III malocclusion

Braz Dent J 24(2) 2013

P.V.P. Oltramari-Navarro et al.

Braz Dent J 24(2) 2013

increases, causing a decrease of the IMPA value (11-13,22).

The use of an Eschler appliance prior to the maxillary
expansion and protraction contributes for a proclination of
the maxillary incisors. After it is used, even with patients
poor compliance, an almost total correction of the anterior
crossbite at IP can be observed.
Concerning the decision of whether or not to expand
the maxillary arch previous to the facial mask protraction,
a study conducted by Vaughn et al. (7) seems important, in
that it showed similar results, between the two treatment
protocols used, leading to the conclusion that the maxillary
expansion did not influence the results obtained (7). On the
other hand, more recent studies performed by Gautam et
al. (21,23) emphasized the need for expansion previous to
protraction. These authors observed a greater displacement
of the craniofacial structures when the expansion was
performed previously. Consequently, the treatment
outcome was more effective due to the greater tension
on the sutural areas, which offers a favorable cellular
response. Maxillary protraction would then be directly
related to the force or tension application on the sutural
area, in that it promoted disarticulation, and rendered the
forward displacement of the maxilla easier. Another result
is bone growth due to bone apposition (4,6,11,12,21,23).
Nevertheless, a consensus prevails on the requirement
of rapid maxillary expansion previous to reverse traction,
when the patient shows upper dental arch atresia or a
posterior crossbite (6,7,11,12,21).
Moreover, it is important to emphasize that the
earlier the intervention, the better the results obtained
(3,5,12). The psychosocial factor is also relevant (12).
Normally, children show discomfort regarding their facial
appearance caused by Class III malocclusion, and face
problems due to the esthetic involvement. Depending on
the severity of the case, an early intervention affords the
child's proper social insertion, without embarrassment or
psychological involvement. Franchi et al. (24) concluded
that early treatment was more effective to control a Class III
malocclusion when it had been started at the initial phase
of the dentition development (end of primary dentition, or
beginning of mixed dentition). This has allowed efficiency
as to maxilla advancement and restriction as to mandibular
growth, as well as correction of the occlusal relationship.
Patients treated in the final phase of mixed dentition also
showed improvements with the maxillary expansion and
protraction treatment, despite their lower results. Early
treatment produces significant post-pubertal changes, both
on the maxilla and the mandible, while a late treatment
only induces a significant restriction of mandibular growth.
Regardless of the time of treatment, correction of the
occlusal relations of Class III malocclusion patients, treated
with rapid maxillary expansion and protraction, followed
172

by fixed appliances seems to produce bone adaptations

instead of dentoalveolar movements. Another advantage
of an early treatment is that if the patient did not reach a
satisfactory outcome during the first maxillary expansion
and protraction, in the pre-pubertal period, a secondary
intervention with this same protocol could be performed
aiming to inhibit mandibular projection (24).
The interceptive approaches of the Class III malocclusion
could be performed with different appliances, including
fixed and removable ones, removable functional appliances,
chincup, protraction headgear, and skeletal anchorage
systems (14,15,17,20,25). The protocol to be chosen is less
important since all appliances seemed to be effective; the
most important issue is related to long-term stability of
this treatment, which relies on the presence of continued
favorable growth (19).
Even with early intervention, stability will depend
on several factors, such as: maxillary and/or mandibular
skeletal involvement, growth potential, age, family history,
genetic influence, as well as patient compliance (4,10).
Therefore, treatment overcorrection has been recommended
to compensate the negative factors.
In conclusion, Class III malocclusion should be
intercepted early, aiming to redirect growth, mainly when
the maxilla is the primary etiologic factor, or when dental
and/or functional factors are involved. The diagnosis,
treatment planning, and prognosis depend on several
characteristics, which should be carefully analyzed by
the orthodontist, such as: patient age, growth potential,
and pattern. The earlier the intervention, the greater
the chances of positive responses, regarding transversal
maxillary advancement and increase. An adequate use
of appliances, with correct application of intensity and
direction, in addition to patient compliance are key
elements for good outcomes.

Resumo
A m ocluso de Classe III esqueltica, com sua imprevisibilidade e natureza
potencialmente desfavorveis, caracteriza um padro de crescimento com
duvidoso prognstico mecnica ortodntica, ainda que esta seja realizada
precocemente. Durante muito tempo, a Classe III foi considerada sinnimo
de prognatismo mandibular, independente das estruturas esquelticas
comprometidas. O crescimento mandibular, determinado essencialmente
por fatores genticos, dificilmente seria controlado pela interveno
ortodntica precoce. Assim, optava-se por aguardar o crescimento e
ento realizar a interveno ortodntica associada cirurgia ortogntica.
A constatao de envolvimento da maxila como etiologia primria na
m ocluso de Classe III foi decisiva para a mudana da teraputica. O
crescimento maxilar, de origem intramembranoso, responderia melhor
ao tratamento por meio do controle e direcionamento do crescimento,
contribuindo para o sucesso da interveno precoce. Em muitos casos,
excelentes resultados so obtidos com a expanso rpida e protrao da
maxila. O presente trabalho objetiva descrever e discutir o tratamento
de uma paciente com m ocluso de Classe III, cujo plano de tratamento
consistiu de duas fases: interceptora, realizada com aparelhos ortopdicos
mecnicos e corretiva, com aparelho ortodntico fixo. Os resultados

deste caso clnico demonstraram que a m ocluso de Classe III deve

ser interceptada o mais precoce possvel, com vistas a redirecionar o
crescimento. Esta abordagem deve acontecer, especialmente, quando
a maxila o fator etiolgico primrio ou quando fatores dentrios e/
ou funcionais estiverem envolvidos na determinao desta m ocluso.
O diagnstico, o plano de tratamento e o prognstico dependem da
idade do paciente, do potencial de crescimento e da severidade da m
ocluso. A interveno precoce, a indicao de aparelhos adequados
e a colaborao do paciente constituem fatores determinantes para a
obteno do sucesso desejado.

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Received August 10, 2012

Accepted April 2, 2013

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Early treatment for skeletal Class III malocclusion

Braz Dent J 24(2) 2013