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Vol. 64, No. 1, Januari-April 2015 | Hal. 1-6 | ISSN 0024-9548
Camouflage orthodontic treatment in skeletal class
III malocclusion with passive self-ligating system
Diah Adisty and KrisnawaƟ
Department of Orthodon cs
Faculty of Den stry, Universitas Indonesia
Jakarta - Indonesia
Correspondence: Diah Adisty, c/o: Departemen Ortodonsia, Fakultas Kedokteran Gigi Universitas Indonesia. Jl. Salemba Raya 4 Jakarta 10430,
Indonesia. E-mail: drg_adisty@yahoo.com
ABSTRACT
Background: Skeletal Class III malocclusion treatment is a difficult case because jaw discrepancies are severe sometimes. However,
in the case of skeletal Class III malocclusion small to moderate level with functional shift where the incisor teeth position can reach
edge to edge relationship in centric relation, then the prognosis will be better. In this case report, treatment of skeletal Class III
malocclusion with functional shifts can be done with orthodontic camouflage, which is intended to fixed malocclusion, eliminating
factors that cause/interfere and create a good interdigitation when the mandible is in centric relation. Purpose: To perform
camouflage orthodontic treatment in skeletal class III malocclusion in order to create a relationship of good dental occlusion. Case:
Female patients, aged 17 years and 9 months old, came to the orthodontic clinic at RSGMP FKGUI with chief complaints of her
upper front teeth position more to the back of the lower front teeth. Clinical examination came with a result of negative overjet,
severe crowding in the upper jaw, asymmetry, concave profile, deviation when jaw closed, and centric occlusion is not the same
with centric relation. Case management: Treatment of skeletal Class III malocclusion is done with camouflage treatment using
the self-ligating system through the anterior teeth of the upper jaw protraction. The selection of self-ligating system was based
on the various advantages, which include low friction between the bracket with archwire, an additional significant and stable
width in intermolar and interpremolar, and the presence of a lip bumper effect. During 15 months of treatment, the result of
overjet becomes positive, teeth are at the arched, asymmetry was corrected, flat profile, and there is no deviation when jaw closed.
Conclusion: In the case of mild and moderate class III malocclusion, orthodontic camouflage is often selected, with or without
extraction (proclination of upper incisor and retroclination of lower incisor were recured). That condition may cause an unstable
treatment results. Therefore, the use of self-ligating brackets will become an appropriate option to reduce flaring effects of upper
incisor teeth by the lateral expansion of the posterior region.
Keywords: Camouflage treatment; skeletal class III malocclusion; passive self ligating
ABSTRAK
Latar belakang: Maloklusi kelas III skeletal merupakan suatu kasus maloklusi yang perawatannya sulit dilakukan karena seringkali
diskrepansi rahang yang terjadi sangat parah. Akan tetapi pada kasus maloklusi kelas III skeletal ringan sampai sedang dengan
adanya functional shift dimana posisi gigi insisif dapat mencapai hubungan edge to edge pada relasi sentrik, maka prognosisnya
menjadi lebih baik. Pada laporan kasus ini, perawatan kasus maloklusi kelas III skeletal yang disertai adanya functional shift dapat
dilakukan secara ortodonti kamuflase, yang ditujukan untuk memperbaiki maloklusi, mengeliminasi faktor penyebab/interfensi dan
menciptakan interdigitasi yang baik saat mandibula berada pada relasi sentrik. Tujuan: Untuk melakukan perawatan ortodonti
kamuflase pada maloklusi skeletal kelas III agar tercipta suatu hubungan oklusi gigi yang baik. Kasus: Pasien perempuan, usia
17 tahun 9 bulan, datang ke klinik ortodonti RSGMP FKGUI dengan keluhan posisi gigi depan atas lebih ke belakang dari gigi
depan bawah. Pemeriksaan klinis terdapat overjet negatif, gigi berjejal parah di rahang atas, asimetri, profil cekung, deviasi saat
penutupan rahang serta oklusi sentrik yang tidak sama dengan relasi sentrik. Tatalaksana kasus: Perawatan maloklusi kelas
2
Adisty and KrisnawaƟ: Camouflage orthodon c treatment in skeletal class III malocclusion
Jurnal PDGI 64 (1) Hal. 1-6 © 2015
III skeletal ini dilakukan dengan perawatan kamuflase menggunakan sistem self-ligating melalui protraksi gigi-gigi anterior
rahang atas. Pemilihan sistem self-ligating dilakukan berdasarkan pertimbangan berbagai kelebihan pada sistem ini, antara lain
friksi yang rendah antara braket dengan archwire, adanya penambahan lebar interpremolar dan intermolar yang signifikan serta
stabil, dan adanya lip bumper effect. Dalam 15 bulan perawatan overjet menjadi positif, gigi-gigi berada pada lengkungnya,
asimetri terkoreksi, profil datar, dan tidak terdapat deviasi saat penutupan rahang. Simpulan: Pada kasus maloklusi skeletal
kelas III ringan dan sedang, perawatan ortodonti kamuflase dapat dilakukan, dengan atau tanpa ekstraksi (proklinasi dari gigi
insisif atas dan retroklinasi dari gigi insisif bawah). Kondisi ini dapat menyebabkan hasil perawatan yang tidak stabil. Oleh karena
itu, penggunaan braket self ligating akan menjadi pilihan yang tepat untuk mengurangi efek proklinasi gigi insisif atas dengan
ekspansi lateral regio posterior.
Kata kunci: Perawatan kamuflase; maloklusi kelas III skeletal; passive self ligating (Damon Q)
INTRODUCTION
Dental aspect of Class III malocclusion is
characterized by the mesiobuccal cusp of the upper
first molar occludes with the mesiobuccal groove
of the lower first molar.1 From skeletal aspect, class
III malocclusion often due to abnormal growth of
the mandible (excessive bone growth), less optimal
maxillary bone growth, or a combination of both.
Class III malocclusion prevalence varies depending
on the type of race. Mongoloid race has the greatest
prevalence in the amount of 12%.1
Skeletal Class III malocclusion is a case in which
the treatment of malocclusion is difficult because
jaw discrepancies are often severe. There is better
prognosis in mild to moderate cases of skeletal
Class III malocclusion with the functional shift
position where the incisor teeth can reach edge to
edge relationship. Treatment of skeletal Class III
malocclusion cases in the presence of functional shifts
can be performed by orthodontic camouflage, which
is intended to correct malocclusion, eliminating
the interference factors and creating a good
interdigitation when the mandible is in centric
relation.
Self-ligating system in orthodontic treatment
uses a bracket fixed to the ligation mechanism in it,
so it can be opened and closed to lock the wire in
the slot without the need for wires or elastomeric
ligation. This system is also provide include a
low friction between the bracket to the archwire,
intermolar and interpremolar additional width that
more significant and stable, and the presence of a
lip bumper effect.3
This case report will discuss the treatment of
Class III malocclusions in the presence of functional
shifts in female patients aged 17 years and 9 months
using passive self-ligation system (Damon Q).
Treatment was intended to eliminate premature
contacts between the upper and lower incisor teeth,
and the profile and occlusion improvements will be
achieved.
CASE
Female patient, student of Faculty of Medicine,
University of Indonesia, aged 17 years 9 months,
came to the clinic RSGMP FKGUI with chief
complaints of upper front teeth are located backward
from the lower front teeth (Figure 1).
Extra-oral clinical examination showed that
patient had mesofacial face, asymmetric and concave
soft tissue profile. Intra-oral clinical examination
showed that oral hygiene and gingiva was moderate,
there was no tooth mobility, palate and tongue was
moderate (Figure 1).
Figure 1.
Photo of extraoral and intraoral patients before
treatment.
Adisty and KrisnawaƟ: Camouflage orthodon c treatment in skeletal class III malocclusion
Jurnal PDGI 64 (1) Hal. 1-6 © 2015
All the permanent teeth have erupted perfectly,
except the unerupted third molars. Left first molar
have missing and replaced with supernumerary
teeth. There was no persistency of decidious teeth.
Right first molar relationship were Class III. Both
canine relationships are class III. Overjet was -3
mm, whereas overbite was 4 mm. There were deep
compensation curve in the upper jaw and lower
jaw, normal curve of Spee, normal midline upper
teeth and lower teeth shift to the left 2 mm. The
shape of the upper and lower dental arches were
oval (Figure 1).
On functional examination, there were no
abnormalities of the temporomandibular joint. There
was a deviation to the left in the opening and closing
of the mandible. There was a vertical interference in
the anterior region (11, 21 to 41, 31). There was also
normal pattern of swallowing and speech. Patients
did not have bad habits. On examination showed
that Centre Occlusion was not the same as the Centre
Relation.
From the results of cephalometric analysis
(Table 1), it can be concluded that there were class
III jaw relationship with the normal maxillary and
mandibular prognatic, concave skeletal profile,
normal mandibular growth direction, normal
vertical growth of the middle and lower face, upper
incisor inclination towards the lower incisor was
retrusive, upper incisor inclination to the cranial
base was protrusive , the lower incisor inclination
of the mandibular plane was retrusive, upper lip
was retrusive with normal lower lip (Figure 2 and
Table 1).
Table 1.
Cephalometric photo.
Cephalometric analysis
Mean
PaƟent
Parameter skeletal (horizontal)
SNA
SNB
ANB
The Wits
Facial Angle
Angle of Convexity
82⁰ ± 2⁰
80⁰ ± 2⁰
2⁰ ± 2⁰
± 1 mm
87⁰ ± 3⁰
0⁰ ± 6⁰
84⁰
86⁰
-2⁰
-10 mm
90⁰
-4⁰
Pg-NB
4 mm
0 mm
60⁰ ± 6⁰
123⁰ ± 7⁰
32⁰ ± 3⁰
64⁰
128⁰
31⁰
130⁰ ± 2⁰
104⁰ ± 6⁰
4 mm ± 2
4 mm ± 2
2 mm ± 2
90⁰ ± 4⁰
134⁰
108⁰
5 mm
4 mm
8 mm
84⁰
4 mm ± 2
7 mm
Parameter skeletal (verƟcal)
Y-axis
Go angle
SN-MP
Parameter dental
Interincisal angle
UI-SN
UI-NA
UI-Apg
LI-Apg
LI-MP
LI-NB
Parameter soŌ Ɵssue
Upper lip-E line
Lower lip-E line
Figure 3.
Figure 2.
3
1 mm ± 2
-6 mm
0 mm ± 2
0 mm
Panoramic radiograph.
Panoramic radiograph showed that 18 and 28
tooth germs both in vertical position, 38 and 48 are in
a mesioangular position. There is a supernumerary
teeth in mandibular left posterior. Alveolar
bone height is normal, as well as the absence of
abnormalities in the maxillary sinus, but less roots
parallel alignment (Figure 3).
Lundstrum analysis indicated a lack of space in
the upper jaw of 10 mm and the lower jaw of 2.5
mm. Meanwhile, Bolton’s analysis showed that the
ratio of anterior teeth with the mesiodistal width of
the mandibular was excess of 3.11 mm compared
to the upper jaw.
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Adisty and KrisnawaƟ: Camouflage orthodon c treatment in skeletal class III malocclusion
Jurnal PDGI 64 (1) Hal. 1-6 © 2015
Kesling analysis was calculated by maintaining
the position of the lower dental arch, to advance
4 mm maxillary forwarding, 2 mm shifting lower
dentition midline to the right. The needs of the space
in the upper jaw was 0 mm and the lower jaw was
-2 mm (right -1,5 mm, left -0.5 mm).
Skeletal factors that play a role in this case is in
the direction of anteroposterior jaw relationship
which is class III malocclusion with mandibular
prognati, and in the transverse directions are
crossbite posterior. Dental factors is the discrepancy
of dental arch and teeth, thus causing crowding
in the maxilla and mandible. There is a vertical
interference in the anterior region, causing mandible
located more anteriorly in centric occlusion.
Female patient, student of Faculty of Medicine,
University of Indonesia, aged 17 years 9 months,
with mesofacial face type, asymmetric and concave
soft tissue profile. Class III jaw relationship with
normal maxillary and mandibular prognati,
concave skeletal profile, normal mandibular growth
direction, normal vertical growth of the middle
and lower face, upper incisor inclination towards
the bottom is retrusive, upper incisor inclination
towards cranial base is normal, the lower incisor
inclination of the mandibular plane is retrusive ,
upper lip retrusive and lower lip normal .Right first
molar relationship is Class III. Canine relationships
are class III. Overjet of -3 mm, whereas overbite of 4
mm. Deep compensation curve in the upper jaw. The
lower dentition midline shift to the left 2 mm. The
need for space in the upper jaw and the lower jaw
of 0 mm at -2 mm (right -1.5 mm, -0.5 mm left).
CASE MANAGEMENT
On functional examination showed that CO and
CR in these patients is not the same. CR examination
showed the upper and lower incisor relationship
edge to edge with overjet of 0 mm, so the camouflage
procedure will be chosen for treatment. Taking
into account the advantages contained in the selfligating bracket, it was decided to use a passive
self ligating system (Damon Q). Standard torque
bracket prescription is used both in the maxilla
and mandible. Camouflage procedures performed
by protraction and intrusion of the maxillary
anterior region by considering the inclination of the
maxillary incisor.
Scaling was started before bonding bracket.
Bracket attached to the upper jaw first. Bonding
bracket on the lower jaw is planned to be carried
out if the relationship is already jumping the bite. In
this case also planned the use of early elastic since
the early stages of treatment. Finishing is done to
obtain a good interdigitation. Then the retention
phase is done by essix retainer on the upper and
lower jaw.
After 15 months of treatment is 7 times the
control visit, the outcome is negative overjet
correction (anterior crossbite) from -3 mm to +2
mm, deep overbite of +4 mm to +2 mm, severe
crowding correction in the upper jaw and light on
mandible, midline shift correction, canine and molar
relationship from class III into class I (Figure 4).
Figure 4.
Photo of extraoral and intraoral patients after 15
months of treatment.
Figure 5.
Cephalometric and panoramic photos of pa ents a er
15 months of treatment.
Adisty and KrisnawaƟ: Camouflage orthodon c treatment in skeletal class III malocclusion
Jurnal PDGI 64 (1) Hal. 1-6 © 2015
Table 2.
Cephalometric Analysis a er 15 months of treatment
Mean
Parameter skeletal (horizontal)
SNA
82⁰ ± 2⁰
SNB
80⁰ ± 2⁰
ANB
2⁰ ± 2⁰
The Wits
± 1 mm
Facial Angle
87⁰ ± 3⁰
Angle of Convexity
0⁰ ± 6⁰
Pg-NB
4 mm
Parameter skeletal (verƟkal)
Y-axis
60⁰ ± 6⁰
Go angle
123⁰ ± 7⁰
SN-MP
32⁰ ± 3⁰
Parameter dental
Interincisal angle
130⁰ ± 2⁰
UI-SN
104⁰ ± 6⁰
UI-NA
4 mm ± 2
UI-Apg
4 mm ± 2
LI-Apg
2 mm ± 2
LI-MP
90⁰ ± 4⁰
LI-NB
4 mm ± 2
Parameter soŌ Ɵssue
Upper lip-E line
1 mm ± 2
Lower lip-E line
0 mm ± 2
Figure 6.
5
Before
treatment
AŌer
treatment
84⁰
86⁰
-2⁰
-10 mm
90⁰
-4⁰
0 mm
86⁰
86⁰
0⁰
-4 mm
86⁰
-4⁰
5 mm
64⁰
128⁰
31⁰
66⁰
130⁰
33⁰
134⁰
108⁰
5 mm
4 mm
8 mm
84⁰
7 mm
117⁰
125⁰
8 mm
8 mm
6 mm
87⁰
5 mm
-6 mm
0 mm
-2,5 mm
0 mm
Superimposi on cephalometric photo on SN field.
Note: The black color shows the pre-treatment
cephalometric. The red color shows the cephalometric
after 15 months of treatment.
Cephalometric superimposition picture before
and after 15 months treatment shows that there are
change in dental, which is a significant maxillary
incisor proclination to obtain a normal overjet. Also
the presence of mandibular rotation in a clockwise
direction. Then the molar relationship of class III
into class I. Good soft tissue profile (Fgure 6 and
Figure 7).
Figure 7.
Profile photos of pa ents before and a er 15 months
of treatment.
DISCUSSION
Camouflage procedurs was chosen because the
functional analysis showed that CO and CR in these
patients is different. CR examination showed that
the upper and lower incisor relationship edge to
edge with overjet of 0 mm. Since there is several
advantages in the self-ligating bracket system, it
was decided to use a passive self ligating system
(Damon Q). Standart bracket prescription was used
on both upper and lower jaw, due to the initial
incisor position and edge to edge incisor relationship
while centric relation. Camouflage procedures
were performed by protraction and intrusion of
the maxillary anterior region by considering the
inclination of the maxillary incisors.
Treatment was preceded by bonding bracket
on the upper jaw. It is intended to obtain positive
overjet by proclination of incisor teeth of the maxilla.
Posterior bite riser was made to free the anterior
bite, so the upper incisor can easily move forward.
Mandibular bracket were bonded when positive
overjet had been achieved. Early elastic mechanism
which is one of the advantages of self-ligating
system was applied, using the class III elastic from
16-43 and 26-33. This procedure was done to get the
canine and molar relationships into class I from the
beginning of treatment.
After 15 months of treatment, the finishing stage
of treatment was achieved,with good interdigitation
at the premolar region. In the cephalometric
superimposition after 15 months of treatment, it
was seen that there were dental changes, with a
significant maxillary incisor proclination and a
normal overjet obtain. Protrusive upper incisor will
6
Adisty and KrisnawaƟ: Camouflage orthodon c treatment in skeletal class III malocclusion
Jurnal PDGI 64 (1) Hal. 1-6 © 2015
be done with labial root torque by using the third
order bend. Proclination incisor did not change the
patient’s upper lip, probably because in the initial
condition the upper right incisor tip position was
at the lower incisor tip position, and the upper lip
was rests on the lower lip in the initial conditions.
Canine and molar relationship were changed from
class III into class I. This might be due to the early
use of Class III elastic at initial treatment.
Presence of mandibular rotation in a clockwise
direction make an elevation in the lower third of
the face. This likely occurred because there was no
interference after the upper incisor teeth had been
protracted.
The conclusion of this case report was that class
III malocclusion is a different case due to severe
jaw discrepancies. However, the prognosis is better
in the mild to moderate Class III malocclusion
cases with incisor tooth position can reach edge
to edge relationship. Therefore in the case of mild
and moderate class III malocclusion, orthodontic
camouflage is often selected, with or without
extraction.
In the camouflage treatment of Class III
malocclusion without extraction, usually proclination
of upper incisor and retroclination of lower incisor
were recured. That condition may cause an unstable
treatment results. Therefore, the use of self-ligating
brackets will become an appropriate option to
reduce flaring effects of upper incisor teeth by the
lateral expansion of the posterior region. Damon
System also has the advantages of early torque
control and a variety of mechanisms that can be
done since the beginning of treatment to correct
the incisor inclination and to obtain good occlusion
after the interference factor is eliminated with the
use of early elastic and the control time interval is
longer than usual.
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