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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 91-96

Clinical correction of class III facial profile in a 15-year-old girl having anterior open bite and lower incisor twinning using reverse pull headgear and fixed orthodontic treatment

1 Department of Oral and Maxillofacial Surgery, PMS Dental College and Research Centre, Thiruvananthapuram, Kerala, India
2 Department of Implantology, Marina Dental Center, Knowledge Village, Dubai, UAE
3 Department of Orthodontics, Naseem Al Rabeeh Medical Center, Doha, Qatar

Date of Web Publication13-Apr-2017

Correspondence Address:
Mathew Tharakan
Department of Oral and Maxillofacial Surgery, PMS Dental College and Research Centre, Thiruvananthapuram, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_18_17

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Use of reverse pull headgear (RPHG) is well advocated and is widely used all over for the early correction of developing Class III malocclusions, mainly in early and late mixed dentition period. Seldom are any articles found, on the use of RPHG in postpubertal girls with Class III facial profiles and anterior open bite. Twinning of teeth usually results from abnormalities in the development of the tooth. Clinically, such a tooth hampers esthetics and the available arch length, which necessitates multidisciplinary intervention. This article reports the successful correction of a 15-year-old girl with Class III profile, anterior open bite and lower incisor twinning.

Keywords: Class III corrections, lower incisor twinning, postpubertal, reverse pull

How to cite this article:
Tharakan M, Surej Kumar L K, Harikrishnan G, Enara SC. Clinical correction of class III facial profile in a 15-year-old girl having anterior open bite and lower incisor twinning using reverse pull headgear and fixed orthodontic treatment. J Int Oral Health 2017;9:91-6

How to cite this URL:
Tharakan M, Surej Kumar L K, Harikrishnan G, Enara SC. Clinical correction of class III facial profile in a 15-year-old girl having anterior open bite and lower incisor twinning using reverse pull headgear and fixed orthodontic treatment. J Int Oral Health [serial online] 2017 [cited 2022 Jan 17];9:91-6. Available from:

  Introduction Top

Although Class III means concave profile where lower jaw stands ahead of the upper jaw, it need not be large or prognathic mandible always. The reasons could be due to normal maxilla with prognathic mandible, retrognathic maxilla with normal mandible or retrognathic maxilla with the prognathic mandible. An appliance like reverse pull headgear (RPHG) which exerts a protrusive force on the maxilla comes into a major role in the management of Class III malocclusions when the maxilla is deficient. It has been suggested that the majority of subjects with a skeletal Class III malocclusion present with maxillary retrusion and a normal or prognathic mandible.[1],[2],[3] It is well established that RPHG produces positive skeletal changes in the maxilla when used in the growing children, but their use in young adults is not much mentioned in the literature. Some authors do not recommend the use of RPHG after sexual maturity.[4],[5] Currently, practiced treatment modality for managing skeletal Class III in young adult patients focuses on orthodontic camoufiage treatment in mild to moderate cases and orthognathic surgery in moderate to severe cases.[6]

The purpose of this article is to suggest the use of RPHG in young adult females with mild Class III skeletal pattern, depending on the anticipated remaining physical growth instead of focusing on the chronological age, onset of puberty, and skeletal maturation. Here, we present a 15-year-old female patient with mild Class III skeletal pattern successfully managed with RPHG and fixed orthodontics, purely on clinical grounds. Even though, lateral ceph tracing and values give the precise nature of the skeletal pattern, a reasonably fair idea about the skeletal pattern could be obtained by a thorough facial profile examination which is even known as “poor man's cephalometric analysis.”[7] As the treatment planning was made solely on clinical assessment, lateral cephalogram was not taken before treatment which also reduces the radiation exposure to young patients.

Disturbances or abnormalities during the development of the tooth can result in anomalies of tooth number, size, shape, and structure. Various terms such as gemination, fusion, concrescence, double teeth, syndontia, and schizodontia have been used to describe dental twinning anomalies. All of these points to some developmental anomalies, where one tooth has combined with another or enlarged itself to the point of doubling or nearly doubling its substance. The complexity of the anomaly depends on the stage of the developing tooth when it is involved.[8],[9] These type of anomalies cause major esthetic concerns when occurs in the anterior region of the mouth. Various treatment modalities for such abnormalities are available, but the morphology of these teeth varies so greatly that treatment options should be decided on an individual case basis.[10],[11]

  Case Report Top

A 15-year-old female patient reported for improving her facial appearance, complaints of the slightly prominent lower jaw, the gap between upper and lower front teeth, and irregular and ugly looking lower teeth. On clinical examination, she revealed the following findings.

Slightly retruded midface, mildly prominent lower jaw, bilateral canines and first molars in 2 mm Class III, OJ – edge to edge, OB – lateral incisor to lateral incisor 1 mm open bite and morphologically altered lower left central incisor [Figure 1],[Figure 2],[Figure 3],[Figure 4].
Figure 1: Pretreatment right lateral profile

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Figure 2: Pretreatment left lateral profile

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Figure 3: Pretreatment oclussion

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Figure 4: Pretreatment twinned lower centrel incisor

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After thorough clinical and radiological (orthopantomogram) examination, she was diagnosed having skeletal III malocclusion with mildly crowded upper and lower labial segments, nil overjet, 1 mm anterior open bite (lateral to lateral), and a twinned lower left lateral incisor [Figure 1],[Figure 2],[Figure 3],[Figure 4].

Although she was post-pubertal female, her feminine characters were not fully developed. Assuming the feasibility of utilizing the anticipated remaining growth, it was decided to start with RPHG therapy and watch for any changes. Root canal treatment (RCT) and reshaping of the lower central incisor were planned at the start of fixed orthodontic treatment.

After starting the RPHG therapy with 350–400 g force on each side with elastic traction and 9–10 h of wear per day, a significant change could be noticed in the first review appointment after 2 months. Due to the positive clinical result for the treatment, it was decided to continue RPHG till favorable anterior overlap is achieved and the patient was treated with 6 weeks review. Within 6 months into RPHG traction, significant vertical and horizontal overlap (around 1.5 mm) could be attained. At this point, before the start of orthodontic treatment, the malformed tooth reshaped which necessitated root canal intervention [Figure 5],[Figure 6],[Figure 7],[Figure 8],[Figure 9],[Figure 10].
Figure 5: Right prolile before fixed ortho treatment

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Figure 6: Left profile before fixed ortho treatment

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Figure 7: Immediate post bonding

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Figure 8: Prior to bonding after 31 reshaping

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Figure 9: Pretreatment croped orthopantomogram of 31

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Figure 10: Posttreatment croped orthopantomogram of 31

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Orthodontic treatment started with 0.022 MBT system. Since the twinned root was left in situ after RCT and reshaping the affected tooth as the left lower central incisor, normal contact between the two lower centrals were not possible. Hence, both the lower central incisor brackets were positioned to allow more mesial inclination of the teeth in the long axis so that the embedded root do not interfere with the mesial contact of the adjoining centrals.

Fixed orthodontic treatment continued with regular 5–6 weeks follow-up intervals. The patient continued wearing the RPHG during the treatment with reduced traction (200–250 g) on each side, until for 6 months into the fixed treatment and then discontinued. Fixed orthodontic treatment completed in 14 months, patient debonded and switched to removable retainers. After the completion of the treatment, the patient had attained positive overjet and overbite of 2 mm, bilateral canines and first molars in Class I relation, normal looking lower left central incisor in contact with the adjacent teeth and the lower lip stays behind the upper lip in profile view [Figure 11],[Figure 12],[Figure 13],[Figure 14],[Figure 15],[Figure 16],[Figure 17],[Figure 18].
Figure 11: Posttreatment occlusion

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Figure 12: Lower centrals with more mesial tilt and in contact

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Figure 13: Posttreatment right lateral profile

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Figure 14: Posttreatment left lateral profile

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Figure 15: Pretreatment orthopantomogram

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Figure 16: Posttreatment orthopantomogram

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Figure 17: Pretreatment cast

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Figure 18: Posttreatment cast

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  Discussion Top

Documented evidence of prominent lower jaw or mandibular prognathism dates back to historical times. After Edward H angle classified malocclusions in the 1890's, mandibular prognathism and the associated facial features became widely known as Class III skeletal pattern. In the earlier periods of dentistry, Angle himself postulated that Class III is entirely due to mandibular excessive growth and the treatment modalities were focused entirely on controlling mandibular growth, mostly chin caps were used for this. Later it became evident that skeletal III could be due to combinations of maxillary and mandibular growth variations and maxillary deficiency is frequently associated with skeletal Class III. The realization of the fact that deficient maxilla is frequently involved with skeletal Class III initiated the possibilities of maxillary protraction in the management of skeletal Class III. Delare's face mask was first introduced in 1971 for the management of skeletal Class III with maxillary deficiency, which exerted elastic traction to the maxilla from an extra oral framework supported on forehead and chin. With the advances in dentistry, some modified and simplified appliance designs are available currently for exerting forward traction on the maxilla and are also called as RPHG.[12],[13],[14],[15]

There is ample literature evidence and it is well proven that RPHG therapy produces positive changes in the maxilla, if used in the growing children, especially in the early and late mixed dentition period.[16] Regarding the efficacy of RPHG for producing changes in the post-pubertal children and young adults, the opinion is not uniform. Baccetti et al.[17] and Wells et al.[18] suggested that for a good chance of success, treatment should begin by the age of 10 at the latest and the chance of successful forward movement is essentially zero by the time sexual maturity is achieved. Kim et al.[19] points that anteroposterior changes can be produced up to the beginning of adolescence, the chance of true skeletal change appears to decline beyond age 8, and the chance of clinical success begins to decline at age 10–11. Cha [20] found that in the postpubertal period, there was a decrease in skeletal effect, whereas the dentoalveolar effect was increased with protraction therapy. Some other researchers found that comparison of the treatment effect according to age showed no significant difference.[21],[22],[23] Yavuz et al.[24] in their study of adolescent and young adult female subjects suggests that protraction face mask therapy in adolescent patients may be most effective, this treatment modality can provide useful results for young adult patients.

The possible undesirable effects of using RPHG includes dental proclination of the maxillary teeth if the traction is attached to the teeth, counterclockwise rotation of the maxilla which can result in open bite, downward and backward (clockwise) rotation of the mandible which increases the lower facial height and retroclination of the lower incisors. Some of these effects such as upper dental proclination and rotation of the mandible help in correcting the Class III skeletal profile. The dental proclination could be managed by redistributing the force applied to the tooth, this can be attained by giving the force to a hook attached on a cap splint or by giving force to a skeletal anchor. The counter-clockwise rotation of the maxilla can be controlled by adjusting the point and direction of force application. Force should be applied close to the center of resistance of maxilla and the direction of force around 30° downward to horizontal. The increase in lower facial height and the retroclination of lower incisors are inevitable, so care should be taken when planning RPHG therapy in patients with increased lower facial height and in true mandibular prognathism where lower incisors are already retroclined. The most important factor in the success of RPHG therapy is the positive response in the circum-maxillary sutures to the applied force and apposition of bone in the sutures, which results in maxillary advancement, for this to happen there should be at least a small fraction of growth potential remaining.[25],[26],[27],[28] The time, duration, and intensity of growth differ among individuals, especially in the case of female children the onset of menstruation or the chronological age cannot be taken as an indicator of cessation of growth. The success of RPHG therapy in postpubertal females lies in the judgment of remaining growth potential if any and utilizing it at the earliest.

Dental twinning results from abnormal events in the embryonic development of the tooth. Although various etiologic factors such as trauma, vitamin deficiencies, systemic diseases, and certain genetic predisposition are suggested as the possible causes, the exact cause is unknown. The overall prevalence appears to be approximately 0.5% in the deciduous teeth and 0.1% in the permanent dentition. Depending on the developmental stage in which the tooth is affected the complexity varies. On clinical grounds, after counting the involved tooth as a single unit, if the total number of teeth in the effected arch is less in number then it is considered as fusion and if the total number of teeth are normal then it is considered as twinning. Since the morphology of the twinned tooth is unique for that particular tooth, treatment options should be decided on individual case basis.[29],[30] In this case, the total number of teeth in the lower arch was normal, and hence it was decided to reshape and maintain the involved tooth as the lower left central incisor.

  Conclusion Top

When planning the treatment options for managing skeletal III malocclusions in postpubertal female patients with mild to moderate maxillary deficiency, clinically identifying the remaining hidden growth potential if any and meticulously using the RPHG could produce successful outcomes rather than proceeding for an orthodontic camouflage or surgical correction at a later stage.

Morphologically altered teeth necessitate individualized treatment approach ranging from simple to skilled multidisciplinary interventions depending on the esthetic, functional concerns they cause and the complexity of the morphological aberrations they possess.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]


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