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Article

Three-Stage Non-Surgical Treatment of Skeletal Class III Malocclusion in Adolescents—A Report of Four Cases with Long-Term Follow-Up

by
Małgorzata Kuc-Michalska
1,
Magdalena Pokucińska
1,
Katarzyna Grocholewicz
2 and
Joanna Janiszewska-Olszowska
2,*
1
Private Orthodontic-Dental Practice “Ortomikar”, 41-800 Zabrze, Poland
2
Department of Interdisciplinary Dentistry, Pomeranian Medical University, 70-204 Szczecin, Poland
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(17), 8095; https://doi.org/10.3390/app14178095
Submission received: 29 July 2024 / Revised: 28 August 2024 / Accepted: 2 September 2024 / Published: 9 September 2024
(This article belongs to the Section Applied Dentistry and Oral Sciences)
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Abstract

:

Featured Application

The method of treatment described may be used in Class III patients, who reject orthognathic surgery.

Abstract

(1) Background: Postponing orthodontic treatment in Class III malocclusion until deterioration and growth cessation to perform orthognathic surgery does not seem to be an optimal solution for every patient. This report describes short- and long-term outcomes for nonsurgical treatment of four adolescents with severe Class III malocclusion. (2) Methods: Four patients (aged 13–15 y) with skeletal Class III (Wits appraisal below 7.5 mm) started a three-stage treatment, consisting of a six-month-long phase I and involving orthopedic treatment with an individual chin-cup. Phase II involved orthopedic treatment with a bonded Haas-type expander on acrylic splints, a face-mask, a lower fixed appliance and Class III elastics; phase III involved full fixed appliance, elastics and reuse of the individual chin-cup. Pre and posttreatment cephalograms were analyzed and superimposed. (3) Results: Improved skeletal and dental relationships and facial appearance was achieved in all patients. Wits appraisal, angles ANB, ANPg and lower face height increased; an improvement of overbite was noted. (4) Conclusions: Severe skeletal Class III in adolescents may be successfully treated with combined orthopedic/camouflage treatment with a Haas-type expander on acrylic splints, Class III elastics, fixed appliance and orthopedic devices (individual chin-cup and facemask) with a very good compliance.

1. Introduction

Treatment of patients with Class III disharmony has been discussed in the literature since Bourdet [1], who described the appearance of patients with protruded chins in 1797. The etiology of this malocclusion can be associated with various combinations of skeletal and dentoalveolar disharmony in one or both jaws [1,2,3]. Favorable dentoskeletal changes induced by combined rapid maxillary expansion and face-mask (RME/FM) treatment in young patients with midface deficiency have been reported by various investigators and have become the standard protocol in young children of different races [3,4,5,6]. However, a lack of stability after early treatment is still a concern for clinicians [3,7,8,9]. The growth potential of the mandible during and after pubertal growth peak influences the long-term success of early treatment [10]. Several studies reported that 20–33% of treated patients have unpredictable, excessive mandibular growth that eventually required orthognathic surgery [3,6,8]. This is also contributed by a longer period of mandibular growth (1 year and 5 months in normodivergent Class III subjects and 2 years 8 months in typical, high-angle Class III subjects) after the cessation of forward growth of the maxilla, especially in boys, compared to Class I individuals [1,2,3,10,11,12,13]. Due to the unknown period of individual mandibular growth and unpredictable growth potential in Class III, most clinicians wait for growth completion before treating these patients with orthognathic surgery [3,14]. Nevertheless, according to recent scientific literature, orthognathic surgery is associated with patients’ preoperative anxiety, post-operative pain and swelling, nutritional restrictions and challenges [15]. Among the complications, there is abnormal bleeding, bad splinting, iatrogenic soft tissue injury, temporary sensory impairment, infection, alteration of the planned occlusion, nasal septum deviation, TMJ disfunction with muscular pain and a skeletal relapse [16].
Moreover, delaying the treatment until adulthood can aggravate problems related to psychosocial, esthetics and functional factors; waiting until growth cessation before orthodontic/surgical intervention is still regarded as a proper solution for patients with severe skeletal Class III disharmony [17].
However, there are concerns related to the surgical correction of Class III subjects and the stability of movements >5 mm of the maxilla and/or >7 mm of the mandible [18,19]. Similarly, another surgical procedure, i.e., surgical-assisted maxillary protraction showed less stability than standard, nonsurgical maxillary face-mask protraction in long-term observations [20].
Moreover, there is still a scarcity of literature on the nonsurgical treatment of skeletal Class III malocclusion in pubertal and postpubertal patients [21,22,23,24,25,26,27,28]. The present article aims to report orthopedic/orthodontic treatment protocols for Class III adolescent (pubertal and postpubertal patients that has been used in our clinic since 2005.

2. Materials and Methods

Four adolescent patients (aged 13.75–14.92 years), two females and two males, with skeletal Class III malocclusions, were treated by one of the authors (M.K.-M.). Pretreatment cephalograms, occlusion and facial appearance of all the patients described has been presented in Figure 1.
Both male patients started treatment at the beginning of the pubertal growth period (CS3 in cervical vertebral maturation), female patient 2 began after the pubertal growth spurt (CS4), and female patient 1 began after the completion of growth, according to CS (CS6), but while still growing in concordance with the body growth chart (Figure 2) and superimpositions [11]. The diagnosis of Class III malocclusion was made based on occlusion, including reverse overjet, angle and canine Class III and cephalometric analysis—there was a negative ANB and negative WITS value below −2. All patients were of European ancestry, had severe skeletal Class III malocclusion with anterior cross-bite and Wits appraisal less than −7.5 (−7.8 mm to −12.93 mm), no permanent teeth congenitally missing or extracted before or during treatment except for the lower third molars, cephalograms of adequate quality available at T1 and at the final observation (T2) after the three-stage nonsurgical treatment. Pre and posttreatment cephalometric measurements are presented in Table 1.
The option of future orthodontic/orthognathic surgery had been offered to the patients with regard to the severity of the skeletal deformities and skeletal maturation [29,30]. All patients and their parents declined the surgical option and decided to try the alternative orthodontic-orthopedic treatment. An informed consent form was signed by all the patients’ relatives before the proposed treatment. The height of the body had been measured for approximately 3–5 months in all patients to carefully detect the body growth changes strictly correlated to the growth of the mandible. The increase in body height has been presented in Figure 2, Figure 3, Figure 4 and Figure 5.
The first phase of the treatment started with the use of an individually prepared chin-cups, with an initial force of 500 g per side on the sagittal plane and 400 g on the vertical plane, to try to gauge the patient’s compliance to orthopedic treatment as presented in Figure 6.
The necessary condition to move to the second phase of the treatment was to achieve improvement in the facial appearance and dental condition. All patients achieved positive changes after the six-month-long treatment. The results of the first phase in patient 3 have been presented in Figure 7.
The second phase of the treatment consisted of the bonded Haas-type expander combined with the face-mask, a lower fixed appliance and long Class III elastics worn full time to enhance maxillary protraction, as described in the literature [22,23,25]. The treatment strategy and course have been presented in Figure 8 and Figure 9.
The acrylic splints of the appliance were formed higher in its posterior part in order to induce intrusion of the lower molars to counteract the clockwise mandibular rotation produced by the face-mask [22,23,25]. At the beginning of the treatment, the contact with the splints was only on the lower second molars, but over time, the strength of the masticatory muscles produced progressive contact with the acrylic splints of the posterior teeth, as visible in Figure 9.
Maxillary protraction with the face-mask was started after the first 10 turns of RME activation, with a forward and downward direction of the protraction force and an inclination of approximately 30° to the occlusal plane [31].
Patients were asked to wear the face-mask for 14 h a day (from 7 pm to 7 am at night and 2 h during daytime), 5 days a week and the whole day, except for meals, on the weekends. The elastics, with a force of 450–550 g per side controlled by a force gauge, were applied from the posterior hooks on the Haas-type appliance (placed between the second premolars and the first molars) to the face-mask. Long Class III elastics, applied to the posterior hooks on the Haas-type expander and the lower first premolar brackets instead of lower canines to reduce the vertical movement of the mandibular incisors, were stretched with an initial force of 150–200 g per side [23,25]. The facial appearance and occlusion of all patients described during the second phase of treatment has been presented in Figure 10.
After cross-bite correction, the most asymmetric female patient (patient 2), with an overgrowth of the right-side body musculature, was instructed to wear Class II elastics on the shorter right side and Class III elastics on the longer left side to intensify the asymmetric traction of the mandible (Figure 11).
The remaining patients still wore Class III elastics on both sides. Patients were instructed to wear these elastics almost full time (except at meal times). The jackscrew of the acrylic expander was turned once a day in the late nighttime to reduce the patients’ pain sensation, 10–28 times as recommended in the literature [23,25,32,33] followed by screw blocking with a portion of KetacTM Cem Radiopaque (3M ESPE, Neuss, Germany) or ligature wire as presented in Figure 12.
The development of median diastema clinically confirmed the separation of a midpalatal suture that appeared in all patients after the 10th turn of the screw. After the spontaneous closing of the diastema during the next four-week period, all patients had intraoral radiographs made to check for the presence of new bone between the central incisors’ roots, as presented in Figure 13.
Then brackets were placed on the upper incisors and canines. Molar tubes in the area of the first premolars were implemented on acrylic splints of RME to enable easy, comfortable placement of the ends of the upper segmental wires visible in Figure 14.
Male patient 3 had asymmetric acrylic splints of RME due to asymmetric constriction of the maxilla as presented in Figure 15.
The third phase of the treatment started after the correction of the reverse overjet and canine to an almost Class II relationship. The acrylic expander was replaced by a full upper fixed appliance. The typical bite changes have been presented in Figure 16.
Slight injuries to the palatal side of the maxilla were detected in each patient. After one month, all injuries had completely disappeared.
Palatal irritation in patient 2 has been presented in Figure 17.
The following occlusal adjustment was then made by means of short and long Class III and II elastics. After achieving a correct dental midline and Class I dental relationship on both sides, Class I triangular elastics were used for the six-month-long stabilization of the occlusion as described in the literature [23,25].

3. The Results of the Treatment

The dental, skeletal and facial changes with treatment were evaluated by selected cephalometric analyses (Björk, McNamara and Jacobson), and superimpositions were made with Dolphin Imaging 11.8 Premium ® by the second author (M.P.) and verified for landmark identification by the third author (J.J.-O.) [34,35,36]. Superimpositions of the four patients have been presented in Figure 18.
All four patients completed the first two orthopedic phases of treatment in 12 months (6 months with chin-cup and 6 months RME/FM, lower FA and Class III elastics) with correction of the anterior cross-bite, achievement of a Class I molar relationship and improvement of the mandibular dental and skeletal asymmetry in patient 2.
The completion of the 3rd phase of treatment with the full fixed appliance took from 6 months in pubertal male patient to 3 to 21 months in postpubertal female patient 2, who has had an endocrinal problem with increased growth hormone levels, even at the age of 22. All patients achieved improved dental and skeletal relationships. The facial appearance and occlusion of four described patients at the final stages of 3rd phase of treatment has been presented in Figure 19.
The final facial appearance and occlusion of the described patients after finish of 3-stage-treatment has been presented in Figure 20.
In patients 1 and 2, the comparison between the pretreatment, posttreatment and follow-up OPGs and lateral cephalograms in the area of mandibular condyle revealed a change of condylar growth direction from those typical for Class III to more vertical ones. The change of the shape of mandibular condyles has been presented in Figure 21.
The posttreatment CBCT of the four patients; the bending of patient 1st and 2nd mandibular condyles confirmed the shape alteration. The shapes of the mandibular condyles of the four described patients have been presented in Figure 22.
Cephalometric analyses comparing pre and posttreatment measurements showed a considerable enhancement in the Wits appraisal in all the patients despite a growth-related increase of the mandibular corpus length Co-Go-Gn, a change in gonial angle Ar-Go-Gn, a proclination of the upper incisors, with the final value of 118.5 to 120.5 degrees, and a change in the inclination of the lower incisors (Table 1).
Superimposition of the pre and posttreatment radiographs showed different changes in the maxillary and mandibular position and shape of each patient. An increase in the mandibular ramus length is due to still-growing mandibles, and the backward/downward chin movement following the downward displacement of maxilla and/or maxillary molars was visible in all patients (Figure 18). The forward movement of the midface in both girls in the postpubertal skeletal stages visible as an increase in Co-A distance seems surprising (Table 1).
The outcomes contributed to an improvement in facial esthetics in all patients. None of the subjects developed any signs of temporomandibular disorders during or after treatment. The anatomical structures of TMJ assessed on posttreatment CBCTs did not reveal any signs of degenerative disease in any of the patients (Figure 22).
For retention, all patients were instructed to wear Essex retainers with hooks to enable the night-time use of Class III elastics to prevent a relapse during the final growth period (Figure 23).
All patients retained a good dental relationship and continuous posttreatment improvement in facial appearance during the 3–8-year follow-up (Figure 24). The facial appearance and occlusion of the described patients has been presented in Figure 24.

4. Discussion

The point of view that orthognathic surgery is the best solution for Class III patients was established many years ago [17]. The RME/FM protocol was thought to be effective from deciduous dentition up to 12 years of age [3,4,5,6,7,8,9,17,28,37,38,39], despite the results by Franchi et al. that indicated that the late use of the RME/FM protocol, i.e., during postpubertal growth stages, induced a significant mandibular growth limitation [31].
It has been shown that RME/FM treatment can produce a backward mandibular rotation, an undesirable change in hyperdivergent Class III patients [37,38,39]. Contrary to RME/FM, Bollard miniplates with Class III elastics enable good orthopedic results up to early adolescence [37]. Class III elastics can stimulate a change in mandibular growth, in addition to a forward mandibular rotation similar to a chin-cup alone or together with elastics [37,38,40,41,42]. The condylar growth direction change, most visible in patient 2, was a classical, desired effect for Class III patients usually found in younger subjects [37,38,39,40,41,42,43]. It limits or even prevents relapse, since such a change is effective in inducing a decrease in the Condylion-Menton distance [37,38,39,40,41,42,44].
The counterclockwise change of the occlusal plane of our adolescents was similar to the results achieved in purely camouflaged orthodontic treatment in prepubertal patients [45]. In the above study, the occlusal plane change with Class III mechanics alone allowed the anteroposterior discrepancy (WITS) to improve about 1.18 mm. In our severe Class III patients, an even higher increase in Wits appraisal was noticed.
The present results are even better than those reported in 2022 in severe postpubertal patients (initial average WITS −9.1 mm) with hybrid-hyrax (HH), alt-RAMEC and miniscrews supported by intraoral Class III elastics [27]. In the above paper, Wits improved on average +2.2 mm, whereas in all of our patients, a greater improvement was observed. The mandibular growth increment (Co-Go-Gn) was +8.9 mm in the hybrid-hyrax study whereas, in ours, it was lower. However, it should be noted that the A-point change was lower in the present study.
The more pronounced mandibular growth restriction in our patients was probably the result of the consecutive use of two extraoral appliances, i.e., the chin-cup and face mask, which doubled the action influencing the still-growing mandible. It could also mean that the use in one patient of two extraoral devices has the greatest potential to modify the development of the mandible during the pubertal and postpubertal stages comapared to other treatment modalities. It is also in agreement with the classical research related to RME/FM versus chin-cup treatment, where in high-angle patients, the chin-cup was more beneficial than the facemask [38].
During our treatments, a proclination of the upper incisors and a retroclination of lower incisors appeared (Table 1). The CBCTs of the incisor area of all patients, made 3 to 7 years after treatment cessation, revealed a favorable bone condition, especially around the upper incisors’ roots, despite changes in their inclination. Contrary to the concerns, the maxillary incisors’ proclination did not cause periodontal problems in either short- or long-term observations (Figure 20, Figure 24 and Figure 25).
In untreated skeletal Class III patients, compensation tends to worsen with age [1,2,3,4,5,6,7,8,9,10,11,12,13,32,37,38,39,40,41,43].
Stability problems after significant movement of the upper and/or the lower jaw during orthognathic surgery seem relevant to the difficulties in neuromuscular adaptation [18,19].
The treatment protocol proposed in the present report, requiring a treatment time about 1.5 to 3 years, produced skeletal modifications slowly and enabled easier neuromuscular adaptation.
The impact of the chin-cup on the lateral pterygoid muscle, which is very often constricted in Class III patients, relying on the slow lengthening of the muscle, facilitated functional, distal movement of the mandible [45,46].
Another advantage of RME, according to a recent systematic review, is associated with a significant increase in nasal cavity and nasopharyngeal dimensions, as measured by CBCT [47]. Similarly, Bellon et al. (2023) have confirmed short-term improvements in upper airway dimensions [48]. Moreover, MARPE is associated with greater long-term skeletal maxillary expansion at the level of the nasal cavity in comparison to conventional RME [49]. The above studies confirm an early study by Wertz (1968), who compared pre and posttreatment airflow volume and stated that opening the palatal suture relieves nasal obstruction of the lower anterior part of the nasal cavity [50].
The fact that maxillary advancement was achieved in adolescent patients may be related to the influence of RME on the spheno-occipital synchondrosis (SOS) [51]. The CBCT research proved that RME procedures affect the SOS length in young individuals [52]. However, it should be kept in mind that the variation of the SOS fusion timing is extensive, and non-fusion was found in adults [51]. Therefore, screw activation of the acrylic expander might positively influence maxillary protraction in adolescents. Class III elastics with the force of 150–200 g per side applied round-the-clock to the dental arches, together with the extraoral elastics with the force of 400–600 g per side, both similar to the literature recommendations, produced positive changes in all patients (Table 1) [23,25,37,38,42].
An enhancement in the Wits appraisal, a small increase in the mandibular corpus length (Co-Gn), except for female patient 1 with endocrinological problems, and a small change in the mandibular angle (Ar-Go-Gn) (Table 1), despite the time-span of increased growth during the pubertal growth spurt and postpubertal stages, proved that the uncontrolled growth of the mandible can be modified.
The smaller-than-expected increase in vertical dimensions was probably an effect of the vertical forces of the chin-cup and the acrylic splints of RME, which doubled the intrusion of the upper and lower molars.
The residual growth of the mandible expected before growth cessation indicates the importance of further mandibular growth modification to avoid relapse, which can be performed with a chin-cup. The authors strongly emphasize that the chin-cup is the only extraoral appliance independent of intraoral constructions; thus, long-term use of it is possible after the completion of FA or RME therapy until the end of growth.
The adaptation and response of the sutures to the traction decreases with age, but the full-day use of Class III elastics produced a continuous force that provided beneficial effects on the sutures, influenced the mandibular functional forward position, visible in most Class III patients as individual adaptation to dental discrepancies, and gradually changed the mandibular position in all patients confirmed by the positive changes in ANB and ANPg, despite the mandibular growth increment [3,53,54,55,56,57].
Superimposition of the pre and posttreatment radiographs showed different beneficial changes in each patient. The same reported study based on 3D CBCT superimpositions were performed on prepubertal patients [58].
The success of the orthopedic/camouflage treatment relies greatly on patient compliance. The progressive improvement in facial appearance resulted in excellent cooperation.
The final outcomes of the treatment protocol described above comprise favorable changes in three different components: (1) dentoalveolar compensations in both jaws and the counterclockwise rotation of the occlusal plane, (2) skeletal modifications consisting of the small but still existing forward/downward displacement of the midface and modification of mandibular growth, and (3) functional backward mandibular movement facilitated by Class III elastics, individual chin-cups and acrylic splints of the bonded expander.
The positive results were more difficult to achieve in our patients due to the fact that they had severe Class III dentoskeletal disharmony [9,31]. The use of two extraoral appliances in pubertal and postpubertal patients resulted in total mandibular length increments despite the still ongoing growth of the mandible. Therefore, the results of the described treatment may expand the current indications for nonsurgical procedures.
It is noteworthy that the growth course or cessation in the present study was determined directly by body height measurements, since the method of cervical vertebral maturation proved unreliable for our Class III patients, as residual growth was still present in the patients during the posttreatment follow-up. We are aware that these results need to be confirmed on a larger sample of pubertal and postpubertal patients.

5. Conclusions

The combined and consecutive orthopedic/camouflage treatment of Class III patients using two extraoral appliances, i.e., the individual chin-cup and a face-mask, together with a bonded Haas-type expander, fixed appliance and Class III elastics results in the improvement of dental and skeletal relationships as well as facial appearance of severe skeletal Class III patients.
Such treatment is an alternative to combined orthodontic/surgical therapy. Two main factors for successful outcome are the patient’s compliance and the orthodontist’s experience.
The growth intensity chart enables a better assessment of residual growth in Class III patients at postpubertal stages, which influences the growth of the mandible, and a more precise identification of mandibular growth termination.

Author Contributions

Conceptualization, M.K.-M.; methodology, M.K.-M.; software, M.P.; validation, M.K.-M., J.J.-O. and M.P.; formal analysis, M.K.-M.; investigation, M.K.-M.; resources, M.K.-M. and M.P.; data curation, M.K.-M.; writing—original draft preparation, M.K.-M.; writing—review and editing, J.J.-O. and K.G.; visualization, M.K.-M.; supervision, M.K.-M. and J.J.-O.; project administration, M.K.-M.; funding acquisition, M.K.-M., J.J.-O. and K.G. All authors have read and agreed to the published version of the manuscript.

Funding

The APC was funded by Pomeranian Medical University in Szczecin, Poland (DNiWZ-342/2024).

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki. An ethical review was performed, and approval was waived for this study by the Ethical Committee of Pomeranian Medical University in Szczecin, Poland (decision reference No KB.006.89.2024; approval date is 12 June 2024).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained by the first author from the patient(s) to publish this paper. One patient could not be contacted—thus the upper part of his face has been removed from the photographs in order to avoid identification.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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Figure 1. Pretreatment cephalograms, occlusion and facial appearance of the patients described.
Figure 1. Pretreatment cephalograms, occlusion and facial appearance of the patients described.
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Figure 2. Changes in body height in patient 1.
Figure 2. Changes in body height in patient 1.
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Figure 3. Changes in body height in patient 2.
Figure 3. Changes in body height in patient 2.
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Figure 4. Changes in body height in patient 3.
Figure 4. Changes in body height in patient 3.
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Figure 5. Changes in body height in patient 4.
Figure 5. Changes in body height in patient 4.
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Figure 6. Individual chin-cup.
Figure 6. Individual chin-cup.
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Figure 7. Facial and occlusal improvement after four months of chin-cup treatment (patient 3).
Figure 7. Facial and occlusal improvement after four months of chin-cup treatment (patient 3).
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Figure 8. Intraoral view during the beginning of the second phase of treatment (in patient 2).
Figure 8. Intraoral view during the beginning of the second phase of treatment (in patient 2).
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Figure 9. Biomechanics of forces and moments during the described treatment with the Haas-type acrylic splints expander, face-mask, an individual chin-cup and Class III elastics (in patient 2). Visible intrusion of posterior teeth under occlusal forces.
Figure 9. Biomechanics of forces and moments during the described treatment with the Haas-type acrylic splints expander, face-mask, an individual chin-cup and Class III elastics (in patient 2). Visible intrusion of posterior teeth under occlusal forces.
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Figure 10. Facial appearance and occlusion during the middle of the second phase of treatment. (A)—patient 1, (B)—patient 2, (C)—patient 3, (D)—patient 4.
Figure 10. Facial appearance and occlusion during the middle of the second phase of treatment. (A)—patient 1, (B)—patient 2, (C)—patient 3, (D)—patient 4.
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Figure 11. Asymmetric elastics in patient 2 to correct mandibular asymmetry.
Figure 11. Asymmetric elastics in patient 2 to correct mandibular asymmetry.
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Figure 12. RME blocked following adequate expansion.
Figure 12. RME blocked following adequate expansion.
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Figure 13. Radiographic examination of the midpalatal suture status: (A) the midpalatal suture opened—brackets cannot be placed due to the lack of bone; thus, there is a probability of root resorption; (B) the visible presence of new bone between incisors’ roots—brackets can be placed on incisors.
Figure 13. Radiographic examination of the midpalatal suture status: (A) the midpalatal suture opened—brackets cannot be placed due to the lack of bone; thus, there is a probability of root resorption; (B) the visible presence of new bone between incisors’ roots—brackets can be placed on incisors.
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Figure 14. Molar tubes in acrylic splints of the Haas-type expander to enable easy and comfortable insertion of the ends of the upper segmental wire into the maxillary anterior part.
Figure 14. Molar tubes in acrylic splints of the Haas-type expander to enable easy and comfortable insertion of the ends of the upper segmental wire into the maxillary anterior part.
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Figure 15. The asymmetric acrylic splints of the Haas-type expander of patient 3 are due to the need of asymmetric expansion of the maxillary width. (A) maxillary shape before treatment, (B) with asymmetric RME, (C) after RME with fixed appliance, (D) after treatment.
Figure 15. The asymmetric acrylic splints of the Haas-type expander of patient 3 are due to the need of asymmetric expansion of the maxillary width. (A) maxillary shape before treatment, (B) with asymmetric RME, (C) after RME with fixed appliance, (D) after treatment.
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Figure 16. The day of replacing the Haas-type expander with an upper fixed appliance in patient 2 and the change from a canine Class II relationship with the acrylic splint-RME to near Class I after removal of the splint-RME. (A)—occlusal relations before debonding of RME, (B)—occlusal relations after debonding of RME and bracket placement on the buccal teeth in maxilla.
Figure 16. The day of replacing the Haas-type expander with an upper fixed appliance in patient 2 and the change from a canine Class II relationship with the acrylic splint-RME to near Class I after removal of the splint-RME. (A)—occlusal relations before debonding of RME, (B)—occlusal relations after debonding of RME and bracket placement on the buccal teeth in maxilla.
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Figure 17. Changes in the palatal shape in patient 2 before and during treatment. (A) before treatment; (B) with a Haas-type acrylic RME; (C) just after removal of the acrylic RME—small injuries to the palatal mucosa are visible in the area of the cervix of the back teeth; (D) one month after the removal of the acrylic RME.
Figure 17. Changes in the palatal shape in patient 2 before and during treatment. (A) before treatment; (B) with a Haas-type acrylic RME; (C) just after removal of the acrylic RME—small injuries to the palatal mucosa are visible in the area of the cervix of the back teeth; (D) one month after the removal of the acrylic RME.
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Figure 18. Superimpositions of four adolescent patients.
Figure 18. Superimpositions of four adolescent patients.
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Figure 19. Cephalograms and photographs of the described adolescent patients at the end of the second phase of the orthopedic/camouflage treatment.
Figure 19. Cephalograms and photographs of the described adolescent patients at the end of the second phase of the orthopedic/camouflage treatment.
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Figure 20. Cephalograms made just before (patient 1 and 4) or just after the end of the treatment (patient 2 and 3), and the facial appearance and occlusion of four adolescent patients just after the end of the 3-stage nonsurgical treatment.
Figure 20. Cephalograms made just before (patient 1 and 4) or just after the end of the treatment (patient 2 and 3), and the facial appearance and occlusion of four adolescent patients just after the end of the 3-stage nonsurgical treatment.
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Figure 21. Orthopanoramic views of four patients: (A) patient 1, (B) patient 2, (C) patient 3 and (D) patient 4; visible alteration of condylar morphology—bending of the condyles of female patients 1 and 2 on posttreatment OPGs; 1-pretreatment OPG, 2-intratreatment OPG, and 3-follow-up OPG.
Figure 21. Orthopanoramic views of four patients: (A) patient 1, (B) patient 2, (C) patient 3 and (D) patient 4; visible alteration of condylar morphology—bending of the condyles of female patients 1 and 2 on posttreatment OPGs; 1-pretreatment OPG, 2-intratreatment OPG, and 3-follow-up OPG.
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Figure 22. CBCTs of TMJ of the four described patients during follow-up period—no signs of degenerative disease.
Figure 22. CBCTs of TMJ of the four described patients during follow-up period—no signs of degenerative disease.
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Figure 23. Essex retainers with hooks to enable the night-time use of Class III elastics.
Figure 23. Essex retainers with hooks to enable the night-time use of Class III elastics.
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Figure 24. Facial appearance and occlusion during the follow-up period.
Figure 24. Facial appearance and occlusion during the follow-up period.
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Figure 25. CBCTs of the incisors area of the described patients taken during follow-up.
Figure 25. CBCTs of the incisors area of the described patients taken during follow-up.
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Table 1. Pre and posttreatment cephalometric measurements.
Table 1. Pre and posttreatment cephalometric measurements.
Patient ID No
Cephalometric Value		Patient 1T2-T1Patient 2T2-T1Patient 3T2-T1Patient 4T2-T1
PretreatmentPosttreatment PretreatmentPosttreatment PretreatmentPosttreatment PretreatmentPosttreatment
ILS-NL112.2121.5+9.3121.3121.20.1117.7118.5−0.8116.9120.8+3.9
ILI-ML72.777.0+4.373.367.8−4.582.877.2−5.678.072.9−5.1
WITS−7.8−2.4+5.4−11.6−6.6+5.0−8.3−4.2+4.1−12.9−4.4+8.5
SNA77.976.9−1.083.983.6−0.387.788.8+1.181.881.6−0.2
SNB81.579.4−2.187.385.9−1.488.088.00.085.182.6−2.5
SNPg83.382.0−1.388.287.5−0.788.088.4+0.485.683.2−2.4
ANB−4.2−2.5+1.7−3.4−2.3+1.1−0.30.8+1.1−3.3−1.0+2.3
ANPg−6.1−5.0+1.1−4.3−3.8+0.5−0.60.6+1.2−3.8−1.6+2.2
NSL/NL6.55.8−0.78.37.1−1.23.4−0.4−3.86.86.9+0.1
NSL/ML31.833.5+1.731.630.8−0.826.527.1+0.634.136.5+2.1
NL/ML25.327.7+2.423.423.7+0.323.127.6+4.127.329.5+2.2
Ar-Go-Gn132.5137.8+5.3135.9130.4−5.5124.3129.2+5.1136.6136.7+0.1
CoA71.977.6+5.776.878.0+1.279.879.7−0.183.482.4−1.0
CoGn108.5116.8+8.3118.2121.7+3.5117.3119.0+2.0128.5126.8−1.7
BaA79.081.9+2.982.085.5+3.583.183.7+0.696.193.0+2.9
BaPg 79.081.9+2.982.085.5+3.583.183.7+0.696.193.0−3.1
LFH102.5107.1+4.6110.1113.1+3.0105.0107.5+2.5110.1113.1+3.0
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Kuc-Michalska, M.; Pokucińska, M.; Grocholewicz, K.; Janiszewska-Olszowska, J. Three-Stage Non-Surgical Treatment of Skeletal Class III Malocclusion in Adolescents—A Report of Four Cases with Long-Term Follow-Up. Appl. Sci. 2024, 14, 8095. https://doi.org/10.3390/app14178095

AMA Style

Kuc-Michalska M, Pokucińska M, Grocholewicz K, Janiszewska-Olszowska J. Three-Stage Non-Surgical Treatment of Skeletal Class III Malocclusion in Adolescents—A Report of Four Cases with Long-Term Follow-Up. Applied Sciences. 2024; 14(17):8095. https://doi.org/10.3390/app14178095

Chicago/Turabian Style

Kuc-Michalska, Małgorzata, Magdalena Pokucińska, Katarzyna Grocholewicz, and Joanna Janiszewska-Olszowska. 2024. "Three-Stage Non-Surgical Treatment of Skeletal Class III Malocclusion in Adolescents—A Report of Four Cases with Long-Term Follow-Up" Applied Sciences 14, no. 17: 8095. https://doi.org/10.3390/app14178095

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