Revista Odontológica Mexicana

Órgano Oficial de la Facultad

de Odontología UNAM

Clinical case

Orthodontic Correction with Camouflage

of Skeletal Class III Patient
Rosa Yaneth Cantero-Becerra 1, Tania Elizabeth Mejía-Avalos 2,
Jacqueline Adelina Rodríguez-Chávez 3, Celia Guerrero-Velázquez 3,
Dora María Rubio-Castillón 3, José Luis Meléndez-Ruíz 3

1.
Alumna de la Especialidad en Ortodoncia. Departamento de Clínicas Odontológicas Integrales. Centro
Universitario de Ciencias de la Salud. Universidad de Guadalajara.
2.
Egresado de la Especialidad en Ortodoncia. Departamento de Clínicas Odontológicas Integrales. Centro
Universitario de Ciencias de la Salud. Universidad de Guadalajara
3.
Profesor de clínica de la Especialidad en Ortodoncia. Departamento de Clínicas Odontológicas Integrales. Centro
Universitario de Ciencias de la Salud. Universidad de Guadalajara

Corresponding author:
José Luis Meléndez-Ruiz.
E-mail: joseluis.melendez@academicos.udg.mx

Received: July 2021

Accepted: March 2022

Cite as:
Cantero-Becerra RY, Mejía-Avalos TE, Rodríguez-Chávez JA, Guerrero-Velázquez C, Rubio-Castillón DM,
Meléndez-Ruíz JL. Orthodontic Correction with Camouflage of Skeletal Class III Patient. Rev Odont Mex.
2022; 26(3): 36-44. DOI: 10.22201/fo.1870199xp.2022.26.3.87876

ABSTRACT

Introduction: One of the main problems in orthodontics treatment with skeletal Class III patients
is making the decision on how to carry out the treatment, deciding whether to perform surgery, or
orthodontic camouflage with or without extractions. A 13-year-old female patient presents with
Class III skeletal, anterior crossbite, straight profile, Class I molar, Class III canine left subdivision.
Objectives: To present the orthodontic follow-up of a Class III patient who underwent orthodon-
tic camouflage without extractions. Case presentation: Prescription MBTTM 0.022” appliances and

D.R.© Universidad Nacional Autónoma de México, Facultad de Odontología. Revista Odontológica Mexicana Órgano Oficial
36 de la Facultad de Odontología UNAM. Vol. 26, Núm. 3, Julio-Septiembre 2022: 36-44
 Rev Odont Mex. 2022; 26(3): 36-44

Essix retainer with acrylic planas direct track were used in the mandibular dental arch, to lift the
bite and give the opportunity to vestibularise the antero-maxillary sector and correct the cross-
bite. Starting with the alignment and levelling phase, using archwires. An orthopantomography
was requested to verticalise roots and was completed with braided archwires and intermaxillary
elastics for detailing. As a result, the anterior crossbite was corrected, the straight profile was
maintained, we achieved Class I molar and canine, and the smile was improved. Conclusions: It
is possible to successfully camouflage a Class III patient as long as we know the skeletal, facial,
dental and functional limits of each patient.

Keywords: Class III skeletal, Camouflage, MBT prescription.

INTRODUCTION

The Class III skeletal relationship has been studied for a long time, and conflicts continue to
exist regarding decision-making about the treatment to be performed. Many cephalometric
analyses have shown that surgical treatment results in a better appearance of the facial profile.
However, it is reported that only in 40% of cases is the ANB angle corrected, formed by the
union of A point (A or subspinal), N (Nasion) and B point (B or supramental), while 52% report
an excessive SNB angle formed by the intersection of S plane (sella)-N and N-B point. While
dental inclinations are modified, the angle of the mandibular incisors ends with an average of
87º while the maxillary incisors can end up with an excess of proclination in a range of 115º.
Not to mention that many times the profile does not achieve a radical change in the patient1.
That is why we must be especially careful when deciding on the type of treatment we will
carry out, and review the dental inclinations in advance, because during the treatment they
could increase and cause unwanted effects. For this reason, several authors have established
reference values to decide between surgery or orthodontic camouflage1-7.
According to Kerr et al.,8 if we have an ANB angle less than -4º, if the inclination of the
mandibular incisor is less than 83º and the Holdaway angle between 7º and 14º, the most
feasible treatment is orthognathic surgery. They also propose that the anteroposterior (A-P)
distance, the inclination of the incisors and the dentofacial appearance are criteria that we
should take as a reference. Stellzig-Eisenhauer et al., consider that the critical limit for per-
forming orthodontic treatment is seen in a 2 mm maxillary incisor protrusion combined with a
3 mm mandibular incisor retrusion3.
Orthodontic camouflage treatment is ideal in patients with mild dentofacial anomalies with
the following inclusion criteria: no growth remnant, slight discrepancy in skeletal relation-
ships, reasonably good dental alignment and no alterations in the vertical or transverse plane.
Stabilization at the end of treatment is of utmost importance; otherwise, the Class III pattern
resumes its growth9,10. One of the most worrying risks during camouflage is the thinning of the
cortices, which is why Stellzig-Eisenhauer et al.,3 point out that the labial and lingual cortices
of the palate, and the symphysis, will be our barriers to dentoalveolar compensation.
Recent studies focus on the importance of using more 3D images as diagnostic methods,
highlighting the variants that could affect the result of our treatments, taking into account
factors such as dental inclinations; discrepancies in the vertical, transverse and anteroposterior
sense, in addition to periodontal approaches such as the cortical bone dimensions, premature 37
 Cantero-Becerra RY, et al. Orthodontic Correction with Camouflage of Skeletal Class III Patient.

contacts and condylar position, to ensure greater stability4,11-13. This paper presents the case of
a patient who underwent orthodontic camouflage of a Class III skeletal without extractions.

CLINICAL CASE PRESENTATION

A 13-year-old female patient, with no relevant medical history, who came to the clinic with the
complaint “I have a bad bite”. Facially, her lower middle third was enlarged, with a round face
and straight profile, a medium nose and thick lips (Figure 1. A). Intraorally, she had permanent
dentition, anterior crossbite, Class I molar malocclusion, Class III canine left with Subdivision,
medium and square teeth, deep bite, mandibular incisors protrusion and maxillary incisors
retrusion, inferior midline deviated 1 mm to the right, diastema between teeth 33 and 34
(Figure 1. B). Square arch shapes, 4 mm overbite, -2 mm overjet, 0 mm curve of Spee, arch
discrepancy with 5.5 mm mandibular excess.

Figure 1. Initial photographs and radiographs. A. Initial extraoral photographs, augmented

lower middle third with straight profile and round face. B. Initial intraoral photographs, anterior
crossbite, Class I molar malocclusion, Class III canine left and Class I right, medium and square
teeth, deep bite, protruded mandibular incisors and retruded maxillary incisors. C. Lateral
radiography of the skull, the skeletal discrepancy is observed with a long mandibular body,
in Lamparski analysis it is in stage 6 of Completion. D. Orthopantomography, patent airway,
38 wider left mandibular ramus, asymmetric condyles, presence of 4 third molar germs.
 Rev Odont Mex. 2022; 26(3): 36-44

Radiographic imaging showed a patent airway, wider left mandibular ramus, asymmetric
condyles, presence of 4 third molar germs, 2:1 root ratio and healthy bone crest levels (Figure
1. C). On the lateral skull radiography, the skeletal discrepancy is observed, with a long man-
dibular body. In the Lamparski analysis it is in stage 6 of Completion (Figure 1. D).
The Steiner Analysis was performed in the Dolphin Imaging software Version 11.8, project-
ing a Class III skeletal with a normal maxilla and mandibular prognathism, proclined mandibular
incisors, retroclined maxillary incisors, counterclockwise growth (Table 1). The objective of the
treatment was to correct the anterior crossbite, maintain a straight profile, maintain Class I
molar, achieve Class I canine, establish an anterior guidance and improve smile, without per-
forming extractions. Fixed prescription appliances MBT slot 0.022” bands with upper double
tubes MBT 0.022”, Essix retainer were placed in the mandibular dental arch with an acrylic
planas direct track in the posterior, to be replaced by appliances. The alignment and levelling
phases, occlusion detailing and final retention (circumferential plate in the maxilla and fixed
lingual retainer in the mandible) continued.

Table 1.
Steiner analysis values before and after treatment.
Standard Initial Final
SNA 82º 83º 83º
SNB 80º 86º 86º
ANB 2º -3º -3º
GO-GN-SN t 31º 31º
SN-Occlusal Plane 14º 17º 14º
Is-NA 22º 13.5º 33º
Is-NA Sec 4mm 3mm 9mm
Is-Plane S-N 103º 97º 116º
Ii-NB 25º 26º 17º
Ii-NB sec 4mm 3mm 1mm
Ii-Mandibular plane 90º 89º 81º
Interincisal 131º 143º 132º

It began only with brackets on the maxillary dental arch with 0.014” Nickel Titanium (NiTi)
archwires, beginning the alignment phase, with stops on maxillary first molars to lift the bite
(Figure 2. A). The alignment continued and a 60-gauge rigid acetate plate with an acrylic planas
direct track was placed on the mandibular dental arch at the posterior level to increase the
bite, facilitating the correction of the anterior crossbite (Figure 2. B).
Once aligned, a 0.016” x 0.022” NiTi archwire was placed. Correction of the anterior crossbite
was achieved after three months, the acetate plate was removed, and tubes and brackets were
placed in the mandibular dental arch with a 0.014” NiTi archwire. Subsequently, a sequence of
0.016” x 0.022” NiTi archwires was followed in the mandibular dental arch and 0.017” x 0.025”
stainless steel (ss) in the maxillary dental arch, the molar-to-molar chain was changed 3 times,
once per month to close gaps (Figure 3).
Once the gaps were closed, the 0.010” metal ligature was placed to prevent them from
opening again. An orthopantomography was taken in order to see parallel roots, the brackets
on teeth 12, 22, 45, 44 and 43 were replaced and 0.017”x0.025” 8-wire braided upper and lower
archwires were used (Figure 3. B). For detailing, 0.017” x 0.025” ss upper and lower archwires 39
 Cantero-Becerra RY, et al. Orthodontic Correction with Camouflage of Skeletal Class III Patient.

Figure 2. Alignment and levelling. A. Start of treatment, alignment and

levelling of maxillary teeth with a 0.014” NiTi archwire, with use of bite
stops to release the anterior teeth. B. 60-gauge rigid acetate plate with an
acrylic addition to correct anterior crossbite, bite stops removed.

Figure 3. Treatment progress. A. 0.017” x 0.025” ss upper archwire, chain

from molar to molar. B. 0.017” x 0.25” ss archwire and metal ligature from
molar to molar to stabilise after having closed the interproximal gaps and
chain from upper left centre to upper right centre to close diastema.

and vector class III 3/16” 4.5 oz intermaxillary elastics were placed. It was concluded with
0.017” x 0.025” braided archwires of 8-strand and continued with ¼” 4.5 oz settling elastics.
Finally, orthodontic appliances were removed. Retention was done with a maxillary circumfer-
ential plate and fixed lingual retention in the mandible.
At the end of the treatment, the straight profile was maintained. Figure 4. A shows improve-
ments in smile, correction of the anterior crossbite. Figure 4. B shows Class I molar and canine
corrections. Good root parallelism (Figure 4. C), maxillary incisors proclination and mandibular
incisors retroclination were obtained (Figure 4. D) (Table 1). In the superimposition, the clock-
wise rotation of the mandible, the downward projection of the chin, the change in the position
of the molars and incisors to achieve compensation can be seen, accompanied by a change in
40 the position of the lips, improving the profile.
 Rev Odont Mex. 2022; 26(3): 36-44

Figure 4. Final photographs and radiographs. A. Final facial photographs from the front and
side. B. Final intraoral photographs showing Class I molar and canine with good occlusal
seating. C. Final lateral skull radiograph: maxillary incisors proclination, mandibular incisors
retroclination, good labial projection. D. Final orthopantomography with good root parallelism.

DISCUSSION

It was decided to treat the patient with camouflage due to the initial clinical characteristics,
making dentoalveolar changes that allowed Class III skeletal to be compensated. Vertical
growth, anteroposterior relationship, inclination of the incisors and facial profile were taken
into account, as some authors recommend4,9,10,14.
The Steiner analysis results showed an ANB of -3, which is therefore within the values to
avoid surgical treatment according to Kerr et al.,8 It is important to highlight that we also use
a slight expansion of the dental arches and use the small spaces in the dental arches to make
the necessary compensation movements. The patient has no remnant of growth, however, the
discrepancy is slight, so it was decided to perform compensation treatment as suggested by
Eslami et al.,2 To establish a correct treatment, it is necessary to analyse the age of the patient,
recommending surgery in patients who have no remaining growth and compensation when
the discrepancies are very slight. 41
 Cantero-Becerra RY, et al. Orthodontic Correction with Camouflage of Skeletal Class III Patient.

Currently, most specialists recommend the use of three-dimensional images for a better
diagnosis, because more points and measurements can be located that help with the skeletal
and soft tissue relationship4,11-13,15,16. However, a two-dimensional image, as in this case, yields
sufficient values to choose the treatment properly. Treating patient with anterior crossbite at
an early age will avoid wear on the incisal edges of the antero-maxillary teeth, as mentioned by
Jang et al.,12 Regarding the wear of teeth in orthodontic treatment, they reveal that among pa-
tients treated with camouflage, adults presented greater wear than adolescents, although this
difference was not significant. There is significance in treating patients without camouflage
at an early age even if the treatment is longer. However, the age at which the patient reached
seeking crossbite correction had already completed their growth. This directly influences treat-
ment decisions and possibilities.
Koo et al.,13 conducted a study to evaluate the width discrepancies in the estimated dental
arch at the centres of resistance; they compared normal occlusion with Class III skeletal mal-
occlusion. They found differences in a transverse direction, attributing in part to the position
of the tongue which, as they explain, does not allow the lingual inclination of the molars, thus
changing the arch shape and causing interference when trying to correct Class III, in addition
to the collapse of the palatal vault. So, they suggest rapid palatal expansion to compensate
for these discrepancies and use 3D images for diagnostics. For this reason, it is important to
classify and measure the dimensions of the basal bone, dental inclinations, contact points
and gingival phenotype of patients. These factors may adversely affect treatment, causing side
effects besides movements such as dehiscence, joint pain, opening the bite, with transverse
and vertical effects. In our case, it was considered that the patient did not present a significant
transverse discrepancy, without the presence of a posterior crossbite, with a favourable gingi-
val phenotype without the need to create rapid palatal expansion, observing good inclination
of the molars where no unfavourable changes were found at the time of decompensation.
Lee et al.,4 evaluated the position of the lips in the Class III skeletal relationship, where they
demonstrated that the most effective way to correct these discrepancies is surgical treatment
of either the maxilla or mandible, or both, and that treatments with camouflage do not achieve
favourable results. Therefore, one of the objectives is to correct the facial profile, we must keep
in mind that the changes are limited when deciding on a camouflage treatment. In the pres-
ent study, the aim was to maintain the dimensions with which the patient presented herself,
without modifying the position of the soft tissues, and this was one of the reasons why it was
decided to compensate without making extractions.
According to a study carried out by Kim et al.,5 compensation for a Class III skeletal is
obtained by proclination of the maxillary incisors and a flattening of the occlusal plane to
obtain a positive overbite. In this case it begins with an occlusal plane of 17º and ends at 14º,
changing the retroclination of the maxillary incisors to a proclination, thus achieving a positive
overbite. De Oliveira et al.,17 presented a clinical case of Class III skeletal that was treated with
a self-ligation braces system and intermaxillary elastics. The results obtained coincide with our
case, although the 0.022” MBT technique was used, so it can be said that a self-ligation braces
system is not mandatory to meet the objectives of Class III skeletal compensation.
Recently, microscrews and miniplates have been used to provide Class III camouflage and
avoid surgery15-18. However, as shown by Ferret et al.,18 this is done in patients with an ANB
angle less than -5 and although the compensation objectives are achieved, the mandibular
incisors end up with greater retroclination, as in their clinical case the incisor mandibular plane
angle ended with 74º. In our case it ended with 81º, which gives us a better prognosis in the
42 stability of the treatment.
 Rev Odont Mex. 2022; 26(3): 36-44

Park et al.,19 recommend using palatal expansion and a protraction mask at night in Class
III patients with a flat mandibular plane angle to induce downward and backward rotation of
the mandible, without the need for extractions. The angle of the mandibular plane presented
in this case is 1º below the norm, so this type of treatment was not considered, avoiding the
discomfort that could be caused by the use of the palatal expander and the protraction mask.

CONCLUSION

Camouflage treatment is a very good option if we know how to accurately diagnose and predict
dental inclinations due to the treatment mechanics that we apply, with good functional and
aesthetic results without the need to extract or perform surgery, reducing treatment time,
post-surgical pain and the additional costs that they represent for the patient.

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