Chang, Chris HN - Point-Counterpoint Conservative Management of Class III Skeletal Malocclusion PDF

Challenging CIII Made Easy
11 mm ?
Chris Chang, DDS, PhD, ABO Certified

Newton’s A & Beethoven Orthodontic Center, Taiwan He was told that only surgery
can solve his problem.
What’s the % of 3 major Honda Y., 20:08
challenging CIII malocclusion?

Good
60%
1. CIII Open bite (High Angle) profile
10% 2. CIII Deep bite
30% 3. CIII with Impaction

1. Anterior
2. Posterior
5 10 10 5 5 5
8:45
I believe in case study... How difficult is that??? 20 08
1. Every case we review

2. Every KEY step we review
3. Be brutally honest to right our wrongs
Pre-Tx
How difficult is that??? How difficult is that???
Discrepancy Index
DI < 10: easy
Rout ine
record
DI = 10~20: moderate
DI = 20~30: difficult
DI > 30: very difficult
Discrepancy Index
How difficult is that???

DI?
Rout ine
71 Very
record
= very, very
difficult!
Discrepancy Index
How difficult is that??? Tx. Plan

A
?
X
os? X
How to measure the difficulty level ???
Discrepancy Index
Tx. Plan
B
Huge gap
X
?
X X
X X
?
Tx. Plan Is that difficult to fix???
C
X
✔
X
Believe me, it’s easy!
No Surger y
Just scre ws
?
22
?
How & Tips???
?
Pre-Tx 22 Post-Tx
Let’s walk through the detailed procedures...
How & Tips???
?
Pre-Tx 22 Post-Tx
KEY:
OP rotation + whole arch distalization by screws
Read & react
0 9
Pre-Tx 22 Post-Tx
20 14
Initial
Without Buccal
0 Shelf Screws,
it would be very hard to fix it.
Mechanics
?????
22 9
Dr. Rungsi
You did the impossible because you

didn’t realize it was impossible.
0
Steve Jobs
Mechanics
?????
0 9 13 20 Dr. Rungsi
Mechanics Mechanics
????? ?????
Dr. Rungsi
9
Mechanics
?????
Dr. Rungsi
12 20
Cha nge Cha nge

the OP the OP
Dr. Rungsi Dr. Rungsi
14 22
Cha nge Cha nge

the OP the OP
I J OI
The Wisdom of Managing Wisdom Teeth
Part III: Methods of Molar Uprighting
Dr. John Lin
Highly Positioned and Transalveolar

Impacted Maxillary Canine
Drs. Billy Su, Chris Chang & W. Eugene Roberts
International Journal of
Stability
A Severe Skeletal Class III Open Bite Orthodontics & Implantology
Malocclusion Treated with Non-surgical Approach
Dr. Sabrina Huang, Lecturer, Beethoven Orthodontic Course (left)
Drs. Sabrina Huang, ChrisHN
Dr. Chris Chang & W.
Chang, Eugene
Director, Roberts Orthodontic Center (middle)
Beethoven
Vol. 24 Oct. 1, 2011
Dr. W. Eugene Roberts, Consultant,
International Journal of Orthodontics & Implantology (right)
This 20-year-8-month-old male presented with a

chief concern of anterior cross bite and prognathic
mandible. He has seen at least two other
orthodontists and was told that surgery is the only
and the lower incisors were inclined 94° to Md
plane. The cephalometric values are summarized
in the Table entitled Cephalometric Summary.
The IBOI ( International Board of Orthdontists and
???
solution for his severe malocclusion. Oral soft tissues, Implantologists) and American Board of Orthodontics
periodontium, frena, and gingival health were all (ABO) discrepancy index (DI) was 71, as documented
█ Fig. 4-5. Pretreatment pano and ceph radiographs
within normal limits. Oral hygiene was excellent. █ Fig 1. Pretreatment facial photographs in the DI worksheet. The patient was succesfully
Medical and dental histories were noncontributory. treated with a conservative camoflogue method as
documented in the finish records (Figs. 6-10).
Pretreatment facial photographs ( Fig. 1 ) showed

a straight profile with protrusive lower lip. The The overall objective of treatment was to keep the
pretreatment intraoral photographs ( Fig. 2 ) and vertical dimension of occlusion (VDO), and retract
study models (Fig. 3) revealed a molar relationship the mandibular incisors, to compensate for the
of bilateral Class III. The lower dental midline was prognathic mandible, in order to achieve a Class I
shifted 1.5 mm to the right of the facial midline. molar and canine relationships with ideal overjet
A lingual cross-bite extended from the right 1 st and overbite. The specific treatment objectives were
Fig 6. Postreatment facial photographs
molar to the left 1 st premolar. There was also an █ Fig 2. Pretreatment intraoral photographs to : █
end-to-end cross-bite tendency extending from the

• Maintain the A-P position of the maxilla.
left 2nd premolar to the 2nd molar. No contributing
• Maintain the position of the maxillary incisors
habits were reported, but the labial tipping of
and molars.
the mandibular incisors suggests a long-term
• Retract the mandible incisors and molars
maxillary lip trap. Intra-oral exam and the panoramic
relative to the apical base of bone.
radiograph (Fig. 4) revealed impaction of the right
#
• Correct the anterior and posterior X-bite and
mandibular third molar ( 32). All other third molars
align the midlines.
were missing.
• Establish a normal overjet and overbite in a
Cephalometric analysis showed a skeletal Class mutually protected, Class I occlusion.
III pattern, due to a prognathic mandible that • Retract upper and lower lips to improve facial
Drs. John Lin, Kwang Bum Park (front row) with Chris Chang and Mark Ou (back row) in front of a collection of
was manifest as a 7-mm anterior cross bite. The balance. rare books in the study room of Dr. Chang s.█On
antique orthodontic Figthe desk lay Angle's
7. Postreatment busts
intraoral made of bronze and
photographs
█ Fig 3. Pretreatment study models colored glaze.
ANB angle was 1.5°, the SN-MP angle was 36°,
International Journal of Orthodontics and Implantology is an experience sharing magazine for worldwide orthodontists
and Implantologists. Download it at http://iaoi.pro
28 29
1.5 years follow-up...

Dr. Sabrina Huang, Lecturer, Beethoven Orthodontic Course (left)
Dr. Chris HN Chang, Director, Beethoven Orthodontic Center (middle)
Dr. W. Eugene Roberts, Consultant,
International Journal of Orthodontics & Implantology (right)
This 20-year-8-month-old male presented with a and the lower incisors were inclined 94° to Md
chief concern of anterior cross bite and prognathic plane. The cephalometric values are summarized
mandible. He has seen at least two other in the Table entitled Cephalometric Summary.
orthodontists and was told that surgery is the only The IBOI ( International Board of Orthdontists and
solution for his severe malocclusion. Oral soft tissues, Implantologists) and American Board of Orthodontics
periodontium, frena, and gingival health were all (ABO) discrepancy index (DI) was 71, as documented
█ Fig. 4-5. Pretreatment pano and ceph radiographs
within normal limits. Oral hygiene was excellent. █ Fig 1. Pretreatment facial photographs in the DI worksheet. The patient was succesfully
Medical and dental histories were noncontributory. treated with a conservative camoflogue method as
documented in the finish records (Figs. 6-10).
Pretreatment facial photographs ( Fig. 1 ) showed

a straight profile with protrusive lower lip. The The overall objective of treatment was to keep the
pretreatment intraoral photographs ( Fig. 2 ) and vertical dimension of occlusion (VDO), and retract
study models (Fig. 3) revealed a molar relationship the mandibular incisors, to compensate for the
of bilateral Class III. The lower dental midline was prognathic mandible, in order to achieve a Class I
I J OI
shifted 1.5 mm to the right of the facial midline. molar and canine relationships with ideal overjet
A lingual cross-bite extended from the right 1 st Dr. John Lin

and overbite. The specific treatment objectives were
Fig 6. Postreatment facial photographs
molar to the left 1 st premolar. There was also an █ Fig 2. Pretreatment intraoral photographs to :
█
end-to-end cross-bite tendency extending from the Malocclusion Treated with Non-surgical Approach
Vol. 24 Oct. 1, 2011
• Maintain the A-P position of the maxilla.
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts
left 2nd premolar to the 2nd molar. No contributing

• Maintain the position of the maxillary incisors
habits were reported, but the labial tipping of
and molars.
the mandibular incisors suggests a long-term
• Retract the mandible incisors and molars
maxillary lip trap. Intra-oral exam and the panoramic
relative to the apical base of bone.
radiograph (Fig. 4) revealed impaction of the right
#
• Correct the anterior and posterior X-bite and
mandibular third molar ( 32). All other third molars
align the midlines.
were missing.
• Establish a normal overjet and overbite in a
Cephalometric analysis showed a skeletal Class mutually protected, Class I occlusion.
III pattern, due to a prognathic mandible that • Retract upper and lower lips to improve facial
was manifest as a 7-mm anterior cross bite. The balance. █ Fig 7. Postreatment intraoral photographs
█ Fig 3. Pretreatment study models
ANB angle was 1.5°, the SN-MP angle was 36°,
28
antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay Angle's busts made of bronze and
colored glaze.
29
Pre-Tx Post-Tx 1.5 y FU
Free download at: 1.5 years follow-up...

1. IAOI.PRO
2. Newtonsa0301
(~300,00 0)
I J OI
Dr. John Lin

Malocclusion Treated with Non-surgical Approach
Drs. Sabrina Huang, Chris Chang & W. Eugene Roberts Vol. 24 Oct. 1, 2011
antique orthodontic rare books in the study room of Dr. Chang s. On the desk lay Angle's busts made of bronze and
Pre-Tx Post-Tx 1.5 y FU

colored glaze.
38
What’s the % of 3 major
60% 1. CIII Open bite (High Angle)
10% 2. CIII Deep bite

1. Anterior Profile
2. Posterior She was told that only surgery
is ???
8:50 can solve her problem.
5 mm: Open bite & OJ - Guru I. 18:00

Humble request:
Surgery is NOT an option!
Pre-Tx
She was told that only surgery

can solve her problem.
5 mm: Open bite & OJ - Guru I. 18:00
Profile
She was told that only surgery
is ???
can solve her problem.
Guru I. What is YOUR Tx Plan???
How to justify
the
No
difficulty Surgery
level?
Profile
is ????
67 + 10 = 77
DISCREPANCY INDEX WORKSHEET
CASE # P(Rev.
ATIENT
9/22/08)
EXAM YEAR
ABO ID#
2009

DI = 77 What is YOUR Tx Plan???
TOTAL D.I. SCORE
OVERJET LINGUAL POSTERIOR X-BITE

0 mm. (edge-to-edge)
1 – 3 mm.
=
=
1 pt.
0 pts. 1 pt. per tooth Total = 0
OJ X-bite
23 6
3.1 – 5 mm. = 2 pts.
5.1 – 7 mm. = 3 pts. BUCCAL POSTERIOR X-BITE
7.1 – 9 mm. = 4 pts.
> 9 mm. = 5 pts.
2 pts. per tooth Total = 0
Negative OJ (x-bite) 1 pt. per mm. per tooth =
CEPHALOMETRICS (See Instructions)
Total =
ANB ≥ 6° or ≤ -2° = 4 pts.
OVERBITE SN-MP
≥ 38° = 2 pts. OB ANB
0 5
0 – 3 mm. = 0 pts.
3.1 – 5 mm. = 2 pts. Each degree > 38° x 2 pts. =
5.1 – 7 mm. = 3 pts.
Impinging (100%) = 5 pts. ≤ 26° = 1 pt.
Total = Each degree < -2° x 1 pt. =
Discrepancy Index
Each degree > 6° x 1 pt. = 1
ANTERIOR OPEN BITE
Open bite SN-MP

Each degree < 26° x 1 pt. =
0 mm. (edge-to-edge), 1 pt. per tooth
15 6
then 1 pt. per additional full mm. per tooth 1 to MP ≥ 99° = 1 pt.
Each degree > 99° x 1 pt. =
Total =
DI < 10: easy

LATERAL OPEN BITE
2 pts. per mm. per tooth OTHER (See Instructions)
Total =
x 1 pt. =
Crowding 1 to MP
Supernumerary teeth
Total = Ankylosis of perm. teeth x 2 pts. =
DI = 10~20: moderate
Anomalous morphology x 2 pts. =
4 0
CROWDING (only one arch) Impaction (except 3rd molars) x 2 pts. =
Midline discrepancy (≥3mm) @ 2 pts. =
1 – 3 mm. = 1 pt. Missing teeth (except 3rd molars) x 1 pts. =
3.1 – 5 mm. = 2 pts. Missing teeth, congenital x 2 pts. =
5.1 – 7 mm. = 4 pts. Spacing (4 or more, per arch) x 2 pts. =
> 7 mm. = 7 pts. Spacing (Mx cent. diastema ≥ 2mm) @ 2 pts. =
x 2 pts. =
DI = 20~30: difficult
Tooth transposition
Total = Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Addl. treatment complexities x 2 pts. =
OCCLUSION Identify:
Occlusion Others
10
Class I to end on = 0 pts.
8
End on Class II or III = 2 pts. per side pts. Total =
No
Full Class II or III = 4 pts. per side pts.
DI > 30: very difficult

Beyond Class II or III = 1 pt. per mm. pts.
additional
OGS
Total =
DI = 77 Tx. Plan
A
X X
Insanely difficult X X
X X
X X
KEYs
Tx. Plan
B 1 Bonding Position
Alignment
X X Marginal Ridge
Root Angulation
Tx. Plan
C 1
X X
X X
✔
DI = 77 ? 1
Believe me, it’s NOT easy!

KEYs KEYs
Idealistic Tx Objectives
1 Bonding Position 1 Bonding Position
OJ X-bite OJ X-bite
Negative OJ -6 mm Negative OJ -6 mm
2 2
#17,15,24,27 #17,15,24,27
Torque Selection OB ANB
Maintain Skeletal CIII Maintain Skeletal CIII
Open bite
Ant. open bite
Crowding
SN-MP
2
Md Angle 35°
1 to MP
3
4 Bite Turbo
✘
Class III Elastics Open bite
Ant. open bite
Crowding
SN-MP
Md Angle 35°
1 to MP
U (Low Q) Space discrepancy Maintain Space discrepancy Maintain
Occlusion Others Occlusion Others

L (High Q) Bilateral Full CIII +11
Midline off
Post. Intrusion Bilateral Full CIII Midline off
KEYs KEYs
Idealistic Tx Objectives
1 Bonding Position 1 Bonding Position
OJ X-bite OJ X-bite
Negative OJ -6 mm Negative OJ -6 mm
2 2
#17,15,24,27 #17,15,24,27
Maintain Skeletal CIII #36,46 GIC
Maintain Skeletal CIII
3 Class III Elastics Open bite

Ant. open bite
SN-MP
Md Angle 35°
3
✘
Ant. open bite
SN-MP
Md Angle 35°
?
Crowding
Space discrepancy
1 to MP
Maintain
4 Bite Turbo
Crowding
Space discrepancy
1 to MP
Maintain
Occlusion Others Occlusion Others

Bilateral Full CIII Midline off
Post. Intrusion Bilateral Full CIII Midline off
KEYs U & L : 14 CuNiTi 3
1 Bonding Position
OJ X-bite
Negative OJ -6 mm
2
#17,15,24,27
3
✘
Ant. open bite
Crowding
SN-MP
Md Angle 35°
1 to MP
Space discrepancy
Occlusion
Maintain
Others
Bite Turbo for posterior intrusion
Bilateral Full CIII Midline off
(Glass Ionomer Cement type II)
KEYs
9
1 Bonding Position
OJ X-bite
Negative OJ -6 mm
2
#17,15,24,27
Buccal Shelf
3
4 Bite Turbo
✘
Ant. open bite
Crowding
SN-MP
Md Angle 35°
1 to MP
Space discrepancy Maintain
2x12 SS
Occlusion Others
5 Screws Bilateral Full CIII Midline off Buccal Shelf : Extra-radicular
KEYs
9
1 Bonding Position
OJ X-bite
Negative OJ -6 mm
2
#17,15,24,27
Buccal Shelf
3
✘
Class III Elastics Open bite SN-MP
✔
Ant. open bite Md Angle 35°
4 Bite Turbo
Crowding
Space discrepancy
1 to MP
Maintain
2x12 SS
Occlusion Others
5 Screws Bilateral Full CIII Midline off Buccal Shelf : Extra-radicular
9 9 14 18
2x12 SS
Buccal Shelf : Extra-radicular
0 3
21
Pre-Tx Post-Tx
9 6
Pre-Tx Post-Tx
12 14
42
21 17
21 42
Pre-Tx Post-Tx
3rd molars
Correction of 3rd
molar takes time!
X X
42 Pre-Tx Post-Tx
-2011.12.23
42
Pre-Tx Post-Tx
NO
Surgery
Pre-Tx Post-Tx
Hard
to
believe!
1. Screw on Buccal Shelf To summary... Initial
3 Keys
Mechanics
?????
Hard to believe! Dr. Rungsi
1. Screw on Buccal Shelf Guru I. 0

3 Keys 2. Posterior Bite Turbos
3. No CIII Elastics
Mechanics
?????
Hard to believe! Dr. Rungsi
To summary... Guru I. 3
Mechanics Mechanics
????? ?????
Dr. Rungsi Chris Dr. Rungsi

Guru I. 3 Guru I. 14
Mechanics Mechanics
????? ?????
Mechanics Mechanics
????? ?????
Mechanics Cha nge

Change OP
????? the OP

Cha nge
the OP
Cha nge
the OP
Guru I. 21 0 9 14 18 42
Cha nge
the OP
Dr. Rungsi
1.5 years follow-up...
Stability
??? Pre-Tx Post-Tx 1.5 y FU
1.5
years follow-up...
Good enough
???
Feu D, Oliveira BH, et al. Influence of Orthodontic

Treatment on Adolescents’ Self-Perceptions of
Esthetics. Am J Orthod Dentofacial Orthop
2012;141 (June): 743-750.
Free download IJOI at IAOI.PRO

What’s the % of 3 major 10:02
1. CIII Open bite (High Angle)
60% 30% 2. CIII Deep bite

1. Anterior
2. Posterior
Class III Deep Bite + Impaction
5 10 10 5 5 5
9:00
NO
10:02
Class III Correction for growing child X

Cl as s III Leve l of
Except: Dx? Di ff ic ulty ?
Fu n c t i o n a l
Dist urbance
Chris Chang
Beethoven, Taiwan
Jessica F. 10:02
10:02 Class III Deep Bite + Impaction? DI=54

DISCREPANCY INDEX WORKSHEET EXAM YEAR 2009

Problem Lists
Cl as s III
CASE # P(Rev.
ATIENT
9/22/08) ABO ID#
TOTAL D.I. SCORE
OVERJET
54 LINGUAL POSTERIOR X-BITE
0 mm. (edge-to-edge)
1 – 3 mm.
3.1 – 5 mm.
=
=
=
1 pt.
0 pts.
2 pts.
1 pt. per tooth Total = 30 Dx? OJ X-bite
5.1 – 7 mm. = 3 pts. BUCCAL POSTERIOR X-BITE
7.1 – 9 mm. = 4 pts.
Negative OJ Narrow Mx.

> 9 mm. = 5 pts.
2 pts. per tooth Total = 0
Negative OJ (x-bite) 1 pt. per mm. per tooth =
CEPHALOMETRICS (See Instructions)
Total = 21 ANB ≥ 6° or ≤ -2° = 4 pts.
OVERBITE
0 – 3 mm.
3.1 – 5 mm.
5.1 – 7 mm.
=
=
=
0 pts.
2 pts.
3 pts.
SN-MP
≥ 38°
Each degree > 38°
=
x 2 pts. =
2 pts.
OB ANB
Impinging (100%) = 5 pts. ≤ 26° = 1 pt.
Total = 5 Each degree < -2°
Each degree > 6°

x 1 pt. =
x 1 pt. = 1
Deep bite Skeletal CIII
Open bite SN-MP
ANTERIOR OPEN BITE
Each degree < 26° x 1 pt. =
0 mm. (edge-to-edge), 1 pt. per tooth
then 1 pt. per additional full mm. per tooth 1 to MP ≥ 99° = 1 pt.
Each degree > 99° x 1 pt. =
Total =
LATERAL OPEN BITE

2 pts. per mm. per tooth OTHER (See Instructions)
Total = 8 - -
Pre-Tx Total
CROWDING (only one arch)

=
Supernumerary teeth
Ankylosis of perm. teeth
Anomalous morphology

Impaction (except 3rd molars)
x 1 pt. =
x 2 pts. =
x 2 pts. =
x 2 pts. = Crowding 1 to MP
Midline discrepancy (≥3mm) @ 2 pts. =
1 – 3 mm. = 1 pt. Missing teeth (except 3rd molars) x 1 pts. =
Mx. crowding -
3.1 – 5 mm. = 2 pts. Missing teeth, congenital x 2 pts. =
5.1 – 7 mm. = 4 pts. Spacing (4 or more, per arch) x 2 pts. =
> 7 mm. = 7 pts.
Spacing (Mx cent. diastema ≥ 2mm) @ 2 pts. =
Tooth transposition x 2 pts. =
Total = 7 Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Addl. treatment complexities x 2 pts. =
OCCLUSION
Class I to end on
End on Class II or III
Full Class II or III
=
=
=
0 pts.
2 pts. per side pts.
4 pts. per side pts.
Identify:
Total = 4
Occlusion Others
Beyond Class II or III = 1 pt. per mm. pts.
Dental CIII Age

additional
Total = 6
DI=54 800
850
-50 ANB -50
Cl as s III
Dx?
U1 to SN0 1130
IMPA 850
2 oz
E-line UL -2mm
E-line LL 5mm
Acceptable Profile in CR
Slightly bimaxillary protrusion
Cl as s III
Dx?
Profile FS
2 oz
? Functional Shift CO CR
Keys to CIII Dx & Tx Planning
Profile
Class FS
Profile
Class
? I have learned this 3-ring diagnosis from Dr. John Lin 27 years ago...
10:02
37
X
1. When?
2. How?
Cl as s III 3. Stabi lity?
Tx Pl an? Pre-Tx Post-Tx
Acceptable profile in CR 37
Severely
Slightly bimaxillary protrusion
What if the major mechanics was: 2 oz
CIII E
Pre-Tx Post-Tx
CO
? CR
37
Result? Pre-Tx Post-Tx

Pre-Tx Post-Tx
37
How?
Let’s walk through the detailed procedures...
37
H uge 1
Ch ange
Low Torq ue
on uppe r ant.
2
1. Hooke’s Law
Bite Turb os Laws 2. Newton’s Law no. 3

Post: GIC-I I
Ant: Resi n 3. Newton’s Law no. 1
Class III E will result in Bi-Max protrusion
0 0
3 20 12
Ope n Coil
Light force
BS screw is a better choice
26 34
3 37 36
Ope n Coil Length???

Light force
> 1∼1.5 bracket width
Should put BS screws early in Tx.
8
31th
0 0 12
20 12
12
0
OPEN & wait

for
auto-eruption
Ope n Coil
Light force
36 How to settle? 36
M elastics
2 oz 2 oz
2~3
Section the main AW weeks
Steffen M, Haltom T. JCO 1987
36
M elastics 36
M elastics
2 oz 2 oz
How long? 2~3
Steffen M, Haltom T. JCO 1987 weeks
36
M elastics Laws
1. Hooke’s Law
2. Newton’s Law no. 3
3. Newton’s Law no. 1
2 oz
How long?
Steffen M, Haltom T. JCO 1987 Hard to believe!
1. Hooke’s Law CR profile
Laws 2. Newton’s Law no. 3 2 stage-tx. (Functional disturbance) If the direction
of U3 is right,
3. Newton’s Law no. 1 Torque Selection NO
Bite Turbo SURGERY
Open coil springs

Elastics / Screws
Hard to believe! 0 37
0 29 CR profile
2 stage-tx. (Functional disturbance)
Torque Selection + Pre-Q -200 (Upper)
Bite Turbo
✔
Open coil springs
ASAP
✘
Elastics / Screws
BS Screws: 31th 0 20 29 37
Class III
0 29 37 Dx + Tx planning + Prognosis
Profile
Class FS
Dr. John Lin
The one who invented this 3-ring diagnosis deserves

BS Screws: 31th the Nobel Ortho Prize.
1.5 years follow-up... There is nothing like writing to force you
to think and get your thoughts straight.
Warren Buffett
Stability
iJOI 27 ABO CASE REPORT iJOI 27 ABO CASE REPORT
iAOI Case Report
Early Intervention of Class III Malocclusion

and Impacted Cuspids in late mixed dentition
HISTORY AND ETIOLOGY

A 10 year 2 month girl was referred by her family dentist for
???
orthodontic consultation (Figure 1). There was no contributory
medical or dental history. Her chief complaint was a protrusive
lower lip with the mouth closed. The relatively severe Class III
developing malocclusion is documented in Figures 2 and 3. The
patient and her parents desired comprehensive orthodontic
treatment to achieve an ideal profile and alignment of the entire
dentition (Figures 4-6). The pretreatment and posttreatment
radiographic documentation is shown in Figures 7 and 8,
Fig 1. Pretreatment facial photographs
respectively. Figure 9 illustrates the influence of the functional
shift on facial esthetics, indicating that the patient is a good
candidate for conservative management of this severe Fig. 7. Pretreatment pano and ceph radiographs show Fig. 8. Posttreatment pano and ceph radiographs show
malocclusion in the late mixed dentition. multiple impacted permanent teeth and retained primary a balancing lip profile.
molar.
The initial clinical examination in centric occlusion
revealed a full Class III malocclusion with an anterior crossbite
of about 5 mm (overjet -5 mm) and an overbite of 5 mm. The
mandibular dental midline was 2 mm to the left of the facial and
maxillary midlines (Figure 7); distally positioned maxillary
incisors with blocked out canines were the contributing factors.
All deciduous teeth were exfoliated except the lower right
primary second molar (Figure 7). The pretreatment panoramic
radiograph (Figure 7) revealed that both maxillary canines were Fig 2. Pretreatment intraoral photographs
superiorly positioned and blocked out. Although the treatment
plan was to achieve an ideal alignment of the impacted cuspids
(Figure 8), there was inadequate space for them to erupt. Figure
10 documents the cephalometric history of the treatment rendered.
DIAGNOSIS ABO CASE REPORT iJOI 27 ABO CASE REPORT iJOI 27
Skeletal :
Skeletal Class III with SNA 79°, SNB 85° and ANB -6° Centric Occlusion Centric Relation
(Figure 7 and Table 1). (CO) (CR)
Normal mandibular plane angle (SN-MP 35°, FMA 33°).
Dental :
Fig. 9. Lateral profile in CO and CR position.
Right end-on Class III molar relationship
Table 1 . Cephalometric summary
Let full cusp Class III molar relationship Fig. 3. Pretreatment study models
News and Trends in Orthodontics (left)
HISTORY AND ETIOLOGY

A 10 year 2 month girl was referred by her family dentist
for orthodontic consultation (Figure 1). There was no
contributory medical or dental history. Her chief complaint
was a protrusive lower lip with the mouth closed. The
relatively severe Class III developing malocclusion is
Be
documented in Figures 2 and 3. The patient and her parents
desired comprehensive orthodontic treatment to achieve an
ideal profile and alignment of the entire dentition (Figures
Fig. 4. Posttreatment facial photographs
4-6). The pretreatment and posttreatment radiographic
documentation is shown in Figures 7 and 8, respectively.
Figure 9 illustrates the influence of the functional shift on
facial esthetics, indicating that the patient is a good candidate
prepared
Fig. 10. Superimposed tracings show retraction of mandibular incisors, tip-back of mandibular molars, flaring
for conservative management of this severe malocclusion in
of maxillary incisors, and favorable growth of the mandible.
the late mixed dentition.
The initial clinical examination in centric occlusion
revealed a full Class III malocclusion with an anterior age, a non-extraction treatment plan with a full fixed tracings document the correction of the malocclusion
crossbite of about 5 mm (overjet -5 mm) and an overbite of 5 orthodontics appliance was indicated (Figure 9). A 0.022” (Figure 10).
mm. The mandibular dental midline was 2 mm to the left of APPLIANCES AND TREATMENT PROGRESS
slot Damon D3MX bracket system (Ormco) was selected
the facial and maxillary midlines (Figure 7); distally
because of the self-ligated feature for inducing light forces 0.022” Damon D3MX® brackets (Ormco) were bonded
fo r reTx .
positioned maxillary incisors with blocked out canines were
to increase arch width and create space for the unerupted on maxillary teeth first because maxillary arch treatment
the contributing factors. All deciduous teeth were exfoliated
Fig. 5. Posttreatment intraoral photographs teeth. To maximize the arch expansion effect, bite turbos was expected to take more time. NiTi open coil springs
except the lower right primary second molar (Figure 7). The
were used to unlock the bite. Class III elastics were used to were placed to create space for the maxillary canines and
pretreatment panoramic radiograph (Figure 7) revealed that
correct the A-P discrepancy by flattening the occlusal plane the maxillary left second premolar. Bite turbos were bonded
both maxillary canines were superiorly positioned and blocked
and opening the vertical dimension of occlusion (VDO). To bilaterally on the maxillary 1st molars to facilitate arch
out. Although the treatment plan was to achieve an ideal
enhance the camouflage effect, short Class III elastics with expansion (Figure 11).
alignment of the impacted cuspids (Figure 8), there was
light force were initiated early in the treatment. To In the 4th month of treatment, the arch wire was
0 37
inadequate space for them to erupt. Figure 10 documents the
compensate for the side effects of Class III elastics, flaring changed to .014X.025 CuNiTi and the activation of the
cephalometric history of the treatment rendered.
of maxillary incisors and retracting mandibular incisors, NiTi open coil springs was retained. The maxillary incisors
DIAGNOSIS low torque brackets were used on maxillary incisors and were protracted to an edge-to-edge position in the 7th month
Skeletal : high torque brackets were bonded on mandibular incisors. of treatment, and an anterior bite turbo were bonded on the
Bilateral extra-alveolar bone screws(2X12 mm, lingual surface of mandibular central incisors to facilitate
Skeletal Class III with SNA 79°, SNB 85° and ANB
OrthoBoneScrew®, Newton’s A, Inc.) in the the buccal overjet and overbite correction (Figure 12 ).
-6° (Figure 7 and Table 1).
shelves were needed to achieve a Class I molar relationship In the 11th month of treatment, the mandibular
Normal mandibular plane angle (SN-MP 35°, FMA
in the final stage of treatment. Superimposed cephalometric teeth were bonded with up-side-down low torque brackets
Fig. 6. Posttreatment study models
1.5 years follow-up... What’s the % of 3 major


30%
2. CIII Deep bite
10%
1. Anterior
2. Posterior
Pre-Tx Post-Tx 1.5 y FU 5 10 10 5 5 5

9:10
There is nothing like writing to force you Johnny C. 14 01

to think and get your thoughts straight.
Warren Buffett
I J OI
The Wisdom of Managing Wisdom Teeth:
Part II. Lower 2nd Molars Extraction to
Prevent Painful and Risky Extraction of
Horizontally Impacted 3rd Molars
Dr. John Lin
Correction of Crowding and Protrusion International Journal of

Complicated by Impacted Molars Bilaterally Orthodontics & Implantology
Dr. W. Eugene Roberts
Vol. 23 JULY 1, 2011
Pre-Tx
0 37
Johnny C. 14 01
Tx Plan
? ?
B
os?
B
C
Johnny C. 14 01
Tx Plan
B
C
✔ B
C
Johnny C. 14 01
X X
B
X X
C C
How to use 0
CBCT in
Imp acte d?
0 Key : Cover with Coe Pak
Video No. 2: Target without Bone
Screen
Capture
Prevent epithelium over-growth to cover the opening
So with CBCT, we perfectly know where they are.

0 3 days later...
Step No. 1
Prevent epithelium over-growth to cover the opening

20 days later...
0 20
Days
OPEN & wait for 60 40

auto-eruption
40 days later... 2X12 mm SS, alveolar ridge
OPEN & wait for

auto-eruption
2 60 days later... 2X12 mm SS, alveolar ridge
2
Months Low torque for labial root torque
2 3 9 9
5 4 9 9
Months BS Screws for lower arch distalization + BT
8 9 9 9
9 9 9 9
Cut the soft tissue BS Screws for lower arch distalization + BT

9 9 9 9
9 9 0 0
2X12 mm SS (Buccal Shelf) to retract Md.
15
8 9
-2010.08.10
15
months in Tx....
15 -2011.12.10
-2011.12.10 Read & react

15 0 3
15 9
15
-2011.12.10 What’s the % of 3 major

30%
2. CIII Deep bite
10%
1. Anterior
2. Posterior
5 10 10 5 5 5
9:15
-2011.12.10
15
Amazing Tx Plan...
?
15 We had fixed CIII & impactions...
15
16 02
Tx.
Plan?
Think 3D
16 02
Tx.
Movie without Bone Plan?
16 02
Tx. Tx.
Plan? OS
Plan?
X X
X X
X
Dilacerated root
16 02
Compound Odontoma
You r
Plan?
Wait for
auto-eruption
Dilacerated root
16 02
5 months later...
Can you fix it?
? L4
Wait for
auto-eruption
If you
My
Pre-surgery Post-surgery
Plan 0
X X
X 20 13
Wait for
auto-eruption
0 9
Dilacerated root mm mm
16 02
OsteoBUR
Osteoclast from
9 1. Dental Follicle
2. PDL
13 mm
auto-eruption
20
13
Stop 2 KEYs:
➟
auto-eruption
1. bone removal
20 20 2. force direction
Next step?
13 = Bone remodeling
Stop 2 KEYs:
➟
auto-eruption
1. bone removal
20 20 2. force direction
4 months = 8 mm
3D Lever Arm
0
Minimally 20
Invasive
24 20
2 KEYs:
1. bone removal
20 2. force direction
?
He was told it is impossible. Force level for Forced eruption???
0 20
> 4 oz & 0 moment???
24 20
Really!
0 20
24 20 Center
0
moment
Amazing progress...
How to Activate? 24 months = 17 mm
Dilacerated
root
3D Lever Arm (2 joints)
6 Keys to Success
1. Dx & Tx plan
2. Bonding Position
One more tip 2 oz

3. Torque Selection
4. Wire Sequence & Timing
5. ELSE + Bite Turbo 1. Deep bite: Ant. BT
2. Open bite: Post. BT
How to Fabricate the 3D Lever Arm

6 Keys to Success
1. Dx & Tx plan
2. Bonding Position
3. Torque Selection
4. Wire Sequence & Timing
5. ELSE + Bite Turbo
6. Screws as a Back-up
46 sec.
I J OI
Dr. John Lin

Vol. 23 JULY 1, 2011
19x25 SS
Drs. Eugene Roberts and Chris Chang in front of a collection of antique orthodontic rare books in the study room of Dr.
Chang s. On the desk lay two human skulls with impacted teeth & Angle's busts made of bronze and colored glaze.
News and Trends in Orthodontics has been renamed as International Journal of Orthodontics and Implantology. You can
read more about this change in this issue of letter from the publisher.
I have learned more from writing
cases than just treating them.
I J OI
Dr. John Lin

Vol. 23 JULY 1, 2011
Drs. Eugene Roberts and Chris Chang in front of a collection of antique orthodontic rare books in the study room of Dr.
Chang s. On the desk lay two human skulls with impacted teeth & Angle's busts made of bronze and colored glaze.
News and Trends in Orthodontics has been renamed as International Journal of Orthodontics and Implantology. You can
read more about this change in this issue of letter from the publisher.
Thank
YOU
0 20
25 20

Chang, Chris HN - Point-Counterpoint Conservative Management of Class III Skeletal Malocclusion PDF

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Challenging CIII Made Easy

Chris Chang, DDS, PhD, ABO Certified

What’s the % of 3 major Honda Y., 20:08

challenging CIII malocclusion?

30% 3. CIII with Impaction

I believe in case study... How difficult is that??? 20 08

1. Every case we review

DI > 30: very difficult

How difficult is that???

How difficult is that??? Tx. Plan

How to measure the difficulty level ???

Believe me, it’s easy!

Let’s walk through the detailed procedures...

How & Tips???

Read & react

You did the impossible because you

Cha nge Cha nge

Cha nge Cha nge

Highly Positioned and Transalveolar

This 20-year-8-month-old male presented with a

Pretreatment facial photographs ( Fig. 1 ) showed

end-to-end cross-bite tendency extending from the

1.5 years follow-up...

Pretreatment facial photographs ( Fig. 1 ) showed

A lingual cross-bite extended from the right 1 st Dr. John Lin

A Severe Skeletal Class III Open Bite Orthodontics & Implantology

left 2nd premolar to the 2nd molar. No contributing

Free download at: 1.5 years follow-up...

Highly Positioned and Transalveolar

Pre-Tx Post-Tx 1.5 y FU

60% 1. CIII Open bite (High Angle)

10% 2. CIII Deep bite

30% 3. CIII with Impaction

5 mm: Open bite & OJ - Guru I. 18:00

She was told that only surgery

5 mm: Open bite & OJ - Guru I. 18:00

OVERJET LINGUAL POSTERIOR X-BITE

Total = Each degree < -2° x 1 pt. =

Open bite SN-MP

DI < 10: easy

x 1 pt. =

DI > 30: very difficult

Believe me, it’s NOT easy!

Occlusion Others Occlusion Others

3 Class III Elastics Open bite

Occlusion Others Occlusion Others

KEYs U & L : 14 CuNiTi 3

Hard to believe! Dr. Rungsi

1. Screw on Buccal Shelf Guru I. 0

Hard to believe! Dr. Rungsi

Dr. Rungsi Chris Dr. Rungsi

Dr. Rungsi Dr. Rungsi

Dr. Rungsi Dr. Rungsi

Mechanics Cha nge

Dr. Rungsi Dr. Rungsi

Dr. Rungsi Dr. Rungsi

Dr. Rungsi Dr. Rungsi

Feu D, Oliveira BH, et al. Influence of Orthodontic

Free download IJOI at IAOI.PRO

challenging CIII malocclusion?

1. CIII Open bite (High Angle)

60% 30% 2. CIII Deep bite

10% 3. CIII with Impaction