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Year : 2013  |  Volume : 31  |  Issue : 4  |  Page : 286-291

Correction of class III malocclusion using modified tandem appliance-two case reports

1 Department of Pedodontics and Preventive Dentistry, Sree Balaji Dental College, Pallikaranai, Chennai, Tamil Nadu, India
2 Department of Pedodontics and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
3 Department of Orthodontics, Sathyabama University Dental College and Hospital, Chennai, Tamil Nadu, India
4 Department of Pedodontics and Preventive Dentistry, Sri Ramachandra Dental College, Porur, Chennai, India
5 Department of Pedodontics and Preventive Dentistry, Kanchi Kamakoti CHILDS Trust Hospital, Nungumbakam, Chennai, India

Date of Web Publication21-Nov-2013

Correspondence Address:
J Jeevarathan
Department of Pedodontics and Preventive Dentistry, Sree Balaji Dental College, Pallikaranai, Chennai - 600 100, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.121835

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Skeletal discrepancies in growing children can have great physical and psychological impact on their appearance. These deformities require orthopedic correction at an appropriate age to avoid future extensive management. Managing a midfacial deficiency or true mandibular prognathism is perhaps the most challenging situation for the clinician. Many orthopedic appliances like chin cup, facemask, and so on have been advocated to correct class III malocclusion. The major problems with these appliances are physical appearance, skin irritation from the anchorage pads and hence, less patient compliance. We present management of class III malocclusion in two children with modified tandem appliance (MTA), which is an intraoral appliance, with no extraoral anchorage, and has better patient compliance and cooperation.

Keywords: Anterior cross bite, class III malocclusion, modified tandem appliance

How to cite this article:
Jeevarathan J, Koora K, Sudhakar V, Muthu M S, Prabhu RV. Correction of class III malocclusion using modified tandem appliance-two case reports. J Indian Soc Pedod Prev Dent 2013;31:286-91

How to cite this URL:
Jeevarathan J, Koora K, Sudhakar V, Muthu M S, Prabhu RV. Correction of class III malocclusion using modified tandem appliance-two case reports. J Indian Soc Pedod Prev Dent [serial online] 2013 [cited 2022 Dec 3];31:286-91. Available from: http://www.jisppd.com/text.asp?2013/31/4/286/121835

   Introduction Top

Dentofacial deformities in growing children necessitate immediate management to improve the profile and function. Class III malocclusion is characterized by retrognathic or short maxilla with normal or prognathic mandible resulting in a class I or class III incisor relationship. The clinical features commonly observed are concave profile, midfacial deficiencies resulting in sunken appearance, relative mandibular prognathism, prominent chin, with anterior cross bite or edge-to-edge relation and narrow maxillary arch with or without posterior cross bite. [1] Class III malocclusion occurs in about 5% of individuals in a North American population but more prevalent in East Asian countries than in Western countries like Japan and China. [2],[3],[4],[5],[6],[7] Its etiology is generally believed to be genetic and familial occurrence has also been demonstrated in several studies. [8],[9] A wide range of environmental factors have been suggested as contributing to the development of class III malocclusion. Among those are enlarged tonsils, difficulty in nasal breathing, congenital anatomic defects, disease of the pituitary gland, hormonal disturbances, a habit of protruding mandible, posture, trauma and disease, premature loss of 6 th year molar, and irregular eruption of permanent incisors or loss of deciduous incisors. [10],[11],[12],[13],[14] Other contributing factors such as the size and relative positions of the cranial base, maxilla and mandible, the position of the temporomandibular articulation and any displacement of the lower jaw affect both the sagittal and vertical relationships of the jaw and teeth. [15],[16],[17],[18] Class III malocclusion can be divided into three groups:

  1. Skeletal type caused by maxillary underdevelopment, mandibular overgrowth or both,
  2. Dental type caused by disharmony of interincisal inclination in a normal skeletal base and
  3. Functional type caused by forward shift of the mandible from occlusal interference (pseudo class III). [19],[20]

Of these, treatment of skeletal malocclusion is the most challenging to the clinician. It is very essential to treat skeletal malocclusion at a very early age, because it influences the skeletal function and tooth position. Many orthopedic appliances have been designed and developed to treat class III malocclusion in growing children. These appliances protract the maxilla and reposition the mandible. They also rotate the mandible in a downward and backward direction, restrict the eruption of mandibular teeth, enhance the eruption of upper molars in a downward and forward direction and are designed for proper occlusion. These appliances also induce dental compensation for skeletal disharmony by linguoversion of mandibular teeth and labioversion of maxillary anterior teeth and more beneficial for patients with normal or reduced anterior facial height. [21] Most commonly reverse pull headgear and expander-facemask appliances, Frankel III and chin cup are used to correct this malocclusion. [22],[23],[24],[25] Other appliances like splint therapy, horseshoe appliance, and tandem traction bow appliance have also been used to correct this malocclusion. [26],[27],[28] Two cases of class III malocclusion corrected using modified tandem appliance (MTA) are presented in this report.

   Appliance Design Top

This appliance has three components, one fixed and two removable. [29] The upper fixed appliance has a hyrax screw and a buccal arm soldered to the bands for elastic traction. The lower appliances comprise a removable acrylic retainer with posterior occlusal coverage and buccal headgear tubes embedded in the area of the lower first molars. Delta clasps on the first permanent molars or second deciduous molars and "C" clasps on the lower deciduous canines are used. Small composite buttons to the labial surfaces of the canines are added so that the "C" clasps will snap over the buttons. A midline expansion screw is also added to the lower appliance to increase the retention. A facebow with the outer bows bent out for elastic attachment is inserted into the lower tubes [Figure 1].
Figure 1: Components of modifi ed tandem appliance

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The original tandem traction bow appliance has two acrylic splints (upper and lower) with a modified facebow for traction. [28]

The upper appliance is first cemented and activated at a rate of one-quarter turn per day. The activation is done for at least 8 to 10 days. The patient is advised to continue wearing the lower appliance but the orthopedic elastic traction is started after definite midline diastema appeared. Heavy orthopedic elastic traction (400 g/14 oz per side) (Leone Orthodontics, Italy) from the facebow to the buccal arms of the upper fixed appliance delivers the protraction force to the maxilla. Initially, the protraction of maxilla was started with only light force of 230 g/ 8 oz (Leone Orthodontics, Italy). The patient is instructed to wear the appliance for at least 10-12 h per day.

   Case Report Top

Case 1

A 6-year-old boy reported to our department with the chief complaint of an unesthetic profile and missing upper anterior teeth. His medical history was noncontributory, but his family history revealed that his father also had the same profile. Clinical examination revealed a significant midfacial deficiency and concave profile suggesting a class III malocclusion [Figure 2]a and b. Intraoral examination revealed an anterior cross bite, missing maxillary left primary central incisor, and caries in right mandibular second and first primary molar and left mandibular second primary molar [Figure 2]c. There were no interference and deviation of mandible on closure. Lateral cephalogram and orthopantomogram were taken to confirm the malocclusion and the presence of underlying permanent teeth. Class I cavity in right and left mandibular second primary molar were restored with composite and the class II cavity in right mandibular first primary molar was restored with a stainless steel crown considering the age of the child and the time the tooth will remain in the oral cavity. The MTA was fabricated and inserted as explained above. The boy was reviewed at an interval of 4 weeks for 16 months (active treatment phase) during which he reported thrice with dislodged and/or broken buccal arm of the appliance which was resoldered and/or recemented. The permanent incisors erupted favorably, profile was also improved [Figure 3]a-c, and appliance was removed 4 months after active treatment. The pretreatment and the posttreatment values of the cephalogram are given in the [Table 1]. Cephalometric evaluation and superimposition revealed a significant skeletal improvement [Table 1], [Figure 4]. The boy was advised to have regular follow-up, as there is a high relapse tendency for skeletal class III malocclusion.
Table 1: Pre- and posttreatment cephalometric measurements of case 1

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Figure 2: Case 1: Pretreatment (a) Frontal; (b): Lateral (c) Intraoral frontal view

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Figure 3: Case 1: Posttreatment (a) Frontal; (b): Lateral (c) Intraoral frontal view

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Figure 4: Case 1: Superimposition of pre- (Blue) and postcephalograms (Red)

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Case 2

An 11-year-old girl reported with a chief complaint of an unesthetic profile. Her medical and family history was noncontributory. Clinical examination revealed midfacial deficiency and concave profile characterizing class III malocclusion [Figure 5]a-c. There were no interference and deviation of mandible on closure. Investigations confirmed class III malocclusion [Table 2]. The upper first permanent molars were banded and a MTA was fabricated and inserted as explained above [Figure 6]. The girl was on regular follow-up. The anterior cross bite was corrected after 9 months of active treatment. The profile also showed a significant improvement [Figure 7]a-c. The appliance was removed 4 months after active treatment phase. Cephalometric evaluation and superimposition revealed a significant skeletal improvement [Table 2], [Figure 8].
Table 2: Pre- and posttreatment cephalometric measurements of case 2

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Figure 5: Case 2: Pretreatment (a) Frontal; (b): Lateral (c) Intraoral frontal view

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Figure 6: Case 2: Elastic traction phase

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Figure 7: Case 2: Posttreatment (a) Frontal; (b): Lateral (c) Intraoral frontal view

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Figure 8: Case 2: Superimposition of pre- (Blue) and postcephalograms (Red)

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   Discussion Top

Treatment of skeletal class III malocclusion is difficult when compared with a nonskeletal class III malocclusion. Functional orthopedic appliances affect the facial skeletal complex of children, activate orthodontic force in teeth and alveolar areas, create a more normal skeletal development and achieve a clinically acceptable esthetic facial profile. These appliances are effective only in growing children. Most commonly facemask or reverse pull headgear is used to correct these malocclusions which use elastics and extraoral anchorage for protraction of maxilla. These appliances also demand special patient compliance, because they are worn extraorally and are not as esthetic or comfortable as intraoral appliance. In the above two cases, we used MTA which was more comfortable to the patient. They are more esthetic and do not require any extraoral anchorage as the other appliances.

Specific diagnosis of skeletal relationships can be made using a number of conventional cephalometric analyses. The pretreatment cephalometric analysis (McNamara, Steiner, Jacobsons Wits) in both the patients confirmed a skeletal class III malocclusion. [30],[31],[32] The McNamara analysis showed that both the patients had an average of 2-4 mm of midfacial length deficiency with normal mandibular values [Table 1] and [Table 2]. Both the patients had a well-established anterior cross bite. The ultimate goals in treating a class III malocclusion are to protract the maxilla to correct the anterior cross bite, restrict the growth of mandible, and establish a stable esthetic profile. Both the patients had horizontal growth pattern which was favorable for our appliance therapy.

Mobilization of the maxillary suture system has become an integral part of orthopedic correction of class III malocclusion in spite of presence or absence of posterior cross bite. This is achieved by expanding the maxilla with rapid maxillary expansion appliances even though no transverse expansion is indicated. This expansion disrupts the circummaxillary suture system, presumably facilitating the response of maxilla for protraction. Oppenheim [33] was one of the first to discuss this possibility. Hass [34],[35],[36],[37] has demonstrated that rapid palatal expansion can produce a slightly forward movement of point A and a slightly downward and forward movement of the maxilla. As there was no posterior cross bite in the above cases, expansion was done to disrupt the circummaxillary suture system.

Profitt stated that the optimal age for maxillary protraction is about 6-7 years. [9] Sullivan recommended such treatment before the age of 10 years or at least 1 or 2 years before the pubertal growth spurt. [37] Both the cases mentioned here were in the optimal age range for protraction of maxilla. The orthopedic elastic traction was started after a definite midline diastema appeared. This indicates that the intermaxillary and circummaxillary sutures are disrupted. In case 1, this was not so apparent as one incisor was missing, but the space between maxillary right central and left lateral incisor increased. Case 2 showed a definite midline diastema. Initially, very light bilateral traction was applied using 8 oz elastics followed by heavy force using 14 oz elastics. The direction of force is determined by the position of the hooks on the upper appliance and the buccal tubes on the lower appliance. They are so positioned that the elastic force passes through the center of resistance of the maxilla (20° to the occlusal plane). [38],[39],[40] During this traction phase, the lower appliance was cemented as it gets dislodged and the patients did not have any soft tissue problems. The patients were more comfortable wearing the appliance for a longer duration everyday.

The duration of treatment of skeletal class III malocclusion varies with individuals. The duration of active treatment phase for the two patients is about 16 months and 9 months. The case 2 had a shorter duration of treatment and greater changes in ANB angle when compared with the case 1. This could be related to the pubertal growth spurt of the female patient. Moreover, case 1 had some interruption during treatment due to the broken buccal arm from the appliance.

The post treatment cephalometric analysis confirmed a significant improvement in the skeletal relationship. The McNamara analysis also showed an average midfacial and mandibular length as per the age. The increase in the mifacial length for both the cases was more than the normal annual increase which is about 1.8 ± 0.5 mm for 6-9-year-old males and 1.7 ± 0.5 mm for 9-12-year-old females. [30] This additional increase in the midfacial length could be due attributed to the elastic traction of the appliance. The change in ANB angle reveals the correction of the overjet and anterior cross bite in both the cases [Table 1] and [Table 2]. As there was significant facial and skeletal improvement, no retention appliances were used and the patients were in regular follow-up so as to prevent any relapse.

   Conclusion Top

MTA is more effective in the treatment of skeletal class III malocclusion. From the above two cases, it is apparent that it induces favorable skeletal changes like maxillary advancement along with restriction of mandibular protrusion, resulting in an esthetic profile.

   References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2]

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