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Year : 2011  |  Volume : 29  |  Issue : 1  |  Page : 57-61

Treatment of pseudo Class III malocclusion by modified Hawleys appliance with inverted labial bow

1 Department of Orthodontics and Dentofacial Orthopedics, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, HP Government Dental College and Hospital, Shimla, Himachal Pradesh, India

Date of Web Publication23-Apr-2011

Correspondence Address:
K S Negi
Department of Orthodontics and Dentofacial Orthopedics, HP Government Dental College and Hospital, Shimla, Himachal Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.79943

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Pseudo Class III malocclusion is characterized by an anterior crossbite with functional forward mandibular displacement. Various appliances have been devised for early treatment of a pseudo Class III. The aim of this article is to highlight the method of construction and use a simple removable appliance termed as "Modified Hawleys appliance with inverted labial bow" to treat psuedo class III malocclusion in the mixed dentition period. It also emphasizes the importance of differentiating between true Class III and pseudo Class III. This appliance in this type of malocclusion enabled the correction of a dental malocclusion in a few months and therapeutic stability of a mesially positioned mandible encouraging favorable skeletal growth.

Keywords: Hawleys appliance with inverted labial bow, psuedo Class III malocclusion

How to cite this article:
Negi K S, Sharma K R. Treatment of pseudo Class III malocclusion by modified Hawleys appliance with inverted labial bow. J Indian Soc Pedod Prev Dent 2011;29:57-61

How to cite this URL:
Negi K S, Sharma K R. Treatment of pseudo Class III malocclusion by modified Hawleys appliance with inverted labial bow. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2023 Feb 3];29:57-61. Available from: http://www.jisppd.com/text.asp?2011/29/1/57/79943

   Introduction Top

Mesioclusion is an anteroposterior dentoalveolar relationship characterized by a more anterior position of the mandibular dentition relative to the maxillary dentition. Characteristics of skeletal Class III malocclusion have been well documented and summarized as follows: Skeletal components with underdeveloped maxilla, overdeveloped mandible, or a combination of both; dentoalveolar components with proclined maxillary incisors and retroclined mandibular incisors to achieve dentoalveolar compensation. [1],[2]

The relative prominence of the mandibular dentition may not be related to differential amounts of jaw growth, but the apparent imbalance in jaw size is considered to be essentially the result of a mesial thrust of the mandible. This malocclusion has been termed pseudo-mesioclusion, apparent Class III, [3] pseudoprognathism, [4],[5] pseudo Class III, postural Class III, [6],[7] and functional Class III. [8]

Moyers suggested pseudo Class III malocclusion as a positional mal-relationship with an acquired neuromuscular reflex. [3] Pseudo Class III malocclusion has been identified with anterior crossbite as a result of mandibular displacement. [9],[10] Premature contact between the maxillary and mandibular incisors results in forward displacement of the mandible in pseudo Class III malocclusion; this displacement disengages the incisors and permits further closure into the position in which the posterior teeth occluded. [10],[11] Several reports attributed the incisor interference to the retroclined upper incisors and proclined lower incisors in pseudo Class III malocclusion. [3],[4],[5],[6],[7],[8],[9],[10],[12],[13]

Comparison of extra-oral photos revealed that the profile of pseudo Class III malocclusion appeared normal at centric relation (CR) and slightly concave at habitual occlusion (HO); moreover, molar relationship was Class I at CR and Class III at HO. [10],[12] Pseudo Class III malocclusion is characterized by certain morphologic, dental, and skeletal characteristics: retrusive upper lip, decreased midface length, retroclined upper incisors, and increased maxillary-mandibular difference. [14]

Different etiological factors are suggested in pseudo Class III malocclusion [8]

Dental factors

  • Ectopic eruption of maxillary central incisors
  • Premature loss of deciduous molars

Functional factors

  • Anomalies in tongue position
  • Neuromuscular features
  • Nasorespiratory or airway problems

Skeletal factors

  • Minor transverse maxillary discrepancy

Management of pseudo Class III malocclusion

The pseudo Class III malocclusion involves both permanent teeth and the deciduous dentition. Because a malocclusion may be regarded as an aesthetic problem, parents often inquire whether a therapy is required. It is difficult to justify the lack of attention given to the timing of treatment of pseudo Class III malocclusion, which remains controversial. [15] Some clinicians believed that in many patients, it was best to allow the eruption of permanent teeth before initiating orthodontic treatment. In this way, a relatively straightforward manner of treatment within a predictable duration could be provided for patients. However, delaying the treatment until permanent dentition errupts may cause loss of space required for eruption of the canines. [3],[10],[13] Some practitioners prefer to wait for the permanent maxillary incisors to erupt before initiating therapy due to the natural tendency of teeth to erupt in a lingual position during dental arch development. Occasionally, functional deciduous anterior crossbites correct themselves spontaneously. White has suggested intervention in cases of pseudo Class III malocclusion in mixed dentition when the maxillary and mandibular incisors have erupted. [16] This allows permanent teeth to erupt in a better position and also improves dental aesthetics.

In general terms, the goal of interceptive orthodontics is to prevent an existing problem from worsening. Specifically, for pseudo Class III, the goals of early treatment are to correct the anterior displacement of the mandible before the eruption of the canines and premolars. Anterior teeth can be guided into Class I in the proper mandibular position, to provide space for eruption of the buccal segments as a result of proclination of the upper incisor, and to provide a normal environment for growth of the maxilla, thus eliminating the anterior crossbite. [10],[15],[17]

From a therapeutic point of view, Graber [6] and others suggested that the mesioclusion must be examined with the mandible guided into a retruded contact position. If the mandibular incisors approach an edge-to-edge occlusion and then slide into anterior displacement, the malocclusion may be pseudo-mesioclusion. Conversely, a true mesioclusion is one in which the mandible cannot be retruded and the pattern of closure is a smooth arch, anteroposteriorly. Various appliances have been devised for early treatment of a pseudo Class III, such as removable plates with springs, fixed or removable inclined planes, functional appliances, chin-cups, and simple fixed appliances. [9],[13],[18]

This case report is intended to illustrate a simple and easy way to manage pseudo Class III by a modified Hawleys appliance with inverted labial bow.

   Case Report Top

A male patient aged 9 years and 6 months, presented with chief complaint of the lower anterior teeth overlapping the upper teeth; his parents were also concerned because of his abnormal facial profile. On clinical examination, a retruded upper lip with prominent lower lip was noted, giving an appearance of midface deficient as seen in class III malocclusion. There was a mesial step molar relationship in centric occlusion with the incisors in crossbite. The dental relationship suggested retroclined upper central incisors, with mild proclination of lower incisors [Figure 1]. The incisors were in end-to-end relationship with posterior open bite when the mandible guided in centric relation. Clinical examination revealed that the displacement occurred due to a premature contact between upper and lower incisors. Therefore, the diagnosis made was a pseudo Class III malocclusion characterized by anterior crossbite and functional mandibular shift in centric occlusion.
Figure 1: Extra- and intra-oral photographs showing class III profile with anterior crossbite

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Appliance design

In order to construct a modified Hawleys appliance, register the bite by guiding the mandible distally in an edge-to-edge incisors relation. Subsequently, transfer the bite in the working model and articulate it in the hinge articulator. After mounting the upper and lower casts remove the construction bite and fabricate an inverted labial bow [Figure 2] and Adams clasp with 0.036'' stainless steel wire. Further, stabilize the inverted labial bow by using wax and construct the acrylic plate as the Hawleys appliance [Figure 2].
Figure 2: The construction of modified Hawleys appliance with inverted labial bow

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Treatment objectives

  • To eliminate CR-CO discrepancy and anterior crossbite
  • To correct Class III and establish Class I canine relationship
  • To achieve normal overjet, and reduce deep bite

Treatment progress

Bite was registered by guiding the mandible distally in incisor edge-to-edge relation for mounting the upper and lower cast in the laboratory. Modified Hawleys appliance was constructed with inverted labial bow. The appliance was delivered with instruction to use it at night for a week and return for follow-up [Figure 3]. After a week, the patient was comfortable and functional shift of mandible occurred in the edge-to-edge incisor relation while closing [Figure 4]. The patient then was asked to use the appliance continuously, except while eating and report after three weeks. With regard to continuous use of appliance for one month, the patient was able to comfortably close the mandible in centric occlusion with positive overbite. Also, there was almost intercuspation in posterior occlusion, with normal lip relation and profile [Figure 5]. The appliance was discontinued after two months when normal occlusion was achieved in centric occlusal relation without the appliance and the patient was advised to use the appliance only at night as a retainer for six months.
Figure 3: Intra-oral photograph showing the position of mandible guided by the appliance at the time of delivery

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Figure 4: Intra-oral photograph showing patient closing mandible in edge-to-edge relation one week after use of the appliance

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Figure 5: Extra- and intra-oral photographs showing the normal profile and occlusion after one month use of the appliance

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   Discussion Top

The various treatments suggested in the literature for correction of anterior crossbite include several different appliances, both fixed and/or removable with heavy intermittent forces (inclined bite plane, tongue blade) or light-continuous forces (removable appliance with auxiliary springs). Other alternative therapies that may correct skeletal problems in young patients have been shown to be effective, with significant changes in the craniofacial complex, including the use of protraction headgear, chincap, and Frankel III. [19],[20],[21],[22] Tsai suggests the use of rapid palatal expansion and standard edgewise appliance to resolve an anterior crossbite in a 7-year-old boy. [23]

Rabie and Gu have described a simple method for early treatment of pseudo Class III malocclusion in the mixed dentition by using fixed appliance. Proclination of the upper incisors and/or retroclination of the lower incisors contribute to the correction of anterior crossbite and elimination of mandibular displacement. [24] Early treatment also permits us to gain space for canine eruption. The therapeutic use of a modified Hawleys appliance with inverted labial bow is suggested in this case report with anterior crossbite in mixed dentition as the simplest way of managing anterior crossbite as compared to other conventional appliances mentioned in the literature.

   Conclusion Top

Modified Hawleys appliance with inverted labial bow is easy to construct and patient-friendly appliance to correct anterior crossbite in Psuedo class-III malocclusion.

Early treatment of Psuedo class III malocclusion helps in:

  • Elimination of mandibular displacement, thus allowing the permanent dentition to be guided into Class I at proper mandibular position
  • Creation of space for eruption of canines and premolars
  • Elimination of traumatic occlusion.

   References Top

1.Hellman M. Morphology of the face, jaws, and dentition in Class III malocclusion of the teeth. J Am Dent Assoc 1931;18:2150-73.  Back to cited text no. 1
2.Guyer EC, Ellis EE, McNamara JA, Behrents RG. Components of Class III malocclusion in juveniles and adolescents. Angle Orthod 1986;56:7-29.   Back to cited text no. 2
3.Moyers RE: Handbook of orthodontics. 3 rd ed. Chicago: Yearbook Medical Publishers; 1973. p. 564-5.  Back to cited text no. 3
4.Jacobson A, Evans WG, Preston CB, Sadowsky L: Mandibular prognathism. Am J Orthod 1974;66:140-71.  Back to cited text no. 4
5.Litton SF, Ackerman LV, Isaacson J, Shapiro BL: A genetic study of Class III malocclusion. Am J Orthod 1970;58:565-577.  Back to cited text no. 5
6.Graber TM: Orthodontics: Principles and practice. 2 nd ed. Philadelphia: WB Saunders Company; 1967. p. 243-8.  Back to cited text no. 6
7.Tulley WJ, Campbell AC: A manual of practical orthodontics. 3 rd ed. Bristol: John Wright and Sons Ltd; 1970. p. 232-9.  Back to cited text no. 7
8.Nakasima A, Ichinose M, Takahama Y: Hereditary factors in the craniofacial morphology of Angle's Class II and Class III malocclusions. Am J Orthod 1982;82:150-6.  Back to cited text no. 8
9.Major PW, Glover K. Treatment of anterior crossbite in early mixed dentition. J Can Dent Assoc 1992;58:574-5,578-9.  Back to cited text no. 9
10.Lee BD. Correction of crossbite. Dent Clin North Am 1978;22:647-68.  Back to cited text no. 10
11.Gravely JF. A study of the mandibular closure path in Angle Class III relationship. Br J Orthod 1984;11:85-91.  Back to cited text no. 11
12.Sharma PS, Brown RV. Pseudo mesiocclusion: Diagnosis and treatment. J Dent Child 1968;35:385-92.  Back to cited text no. 12
13.Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with functional appliance, 2 nd ed. St Louis: Mosby; 1997. p. 462-70.  Back to cited text no. 13
14.Rabie AB, Gu Yan. Diagnostic criteria for pseudo-Class III malocclusion Am J Orthod Dentofacial Orthop 2000;117:1-9.  Back to cited text no. 14
15.McNamara JA, Burudon JW. Orthodontic and orthopedic treatment in the mixed dentition. Ann Arbor: Needham Press; 1993. p. 3-8.  Back to cited text no. 15
16.White L, Hobbs NM. Early orthodontic intervention. Am J Orthod Dentofac Orthop 1998;113:24-8.  Back to cited text no. 16
17.Gu Y, Rabie AB, Ha¨gg U. Treatment effects of simple fixed appliance and reverse headgear in correction of anterior crossbites. Am J Orthod Dentofacial Orthop 2000;117:691-9.  Back to cited text no. 17
18.Proffit WR. Contemporary Orthodontics. 3 rd ed. St Louis: Mosby; 2000. p. 276-7.  Back to cited text no. 18
19.Ngan P, Hgg U, Yiu CK, Merwin D, Wei SH. Treatment response to maxillary expansion and protraction. Eur J Orthod 1966;18:151-68.  Back to cited text no. 19
20.Allen RA, Connoly IH, Richardson A. Early treatment of Class III incisor relationship using the chincap appliance. Eur J Orthod 1993;15:371-6.  Back to cited text no. 20
21.Nanda R. Protractions of maxilla in rhesus monkeys by controlled extraoral forces. Am J Orthod Dentofac Orthop 1978;74:121-41.  Back to cited text no. 21
22.Turley PK. Orthopedic correction of Class III malocclusion: Retention and phase II therapy. J Clin Orthod 1996;6:313-24.  Back to cited text no. 22
23.Tsai HH. Treatment of anterior crossbite with bilateral posterior crossbite in early mixed dentition: A case report. J Clin Pediat Dent 2000;24:181-6.  Back to cited text no. 23
24.Rabie AB, Gu Y. Management of pseudo-Class III malocclusion in southern Chinese children. Br Dent J 1999;186:183-7.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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