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Year : 2022  |  Volume : 33  |  Issue : 3  |  Page : 338-343
Multi-disciplinary orthodontic camouflage treatment of a severe skeletal class III malocclusion with 1 year follow-up – A case report

1 Department of Orthodontics and Dentofacial Orthopedics, Opal Dentistry, Chennai, Tamil Nadu, India
2 Department of Orthodonticsa nd Dentofacial Orthopedics, Meenakshi Ammal Dental College and Hospital, Maduravoyal, Chennai, Tamil Nadu, India

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Date of Submission31-May-2020
Date of Decision17-Oct-2020
Date of Acceptance25-Sep-2022
Date of Web Publication17-Jan-2023


Rationale: Orthodontic camouflage serves its purpose in treating mild to moderate skeletal dysplasia and in conditions where the patient is reluctant to opt for orthognathic surgery or when it is contraindicated. Patient Concerns: A 22-year-old male was concerned about his irregular teeth. Diagnosis: Angle's dentoalveolar class III malocclusion on class III skeletal on an average mandibular plane angle with anterior crossbite, deep bite, crowding in maxillary and mandibular anteriors, proclined maxillary anteriors and retroclined mandibular anteriors with reverse overjet and congenitally missing 12, 22, palatally impacted 13 and retained deciduous 63 and palatally placed 23. Treatment: Orthodontic camouflage with a multi-disciplinary approach. Outcome: Optimal functional and dentofacial aesthetics were achieved by 22 months. Take-Away Lesson: The limitations of camouflage must be kept in mind and explained to the patient. The biomechanics need to be customized and integrating different specialties helps maximize the treatment benefits.

Keywords: Camouflage, mandibular incisor extraction, skeletal class III

How to cite this article:
Adeni MK, Parameswaran R, Vijayalakshmi D, Sainulabdeen J. Multi-disciplinary orthodontic camouflage treatment of a severe skeletal class III malocclusion with 1 year follow-up – A case report. Indian J Dent Res 2022;33:338-43

How to cite this URL:
Adeni MK, Parameswaran R, Vijayalakshmi D, Sainulabdeen J. Multi-disciplinary orthodontic camouflage treatment of a severe skeletal class III malocclusion with 1 year follow-up – A case report. Indian J Dent Res [serial online] 2022 [cited 2023 Feb 5];33:338-43. Available from:

   Introduction Top

The optimal treatment plan in severe Class III skeletal deformity is a combination of orthodontics and surgical intervention. However, many patients are reluctant to undergo surgery. In these patients, orthodontic camouflage is indicated since it involves solving a dento-skeletal problem through dentoalveolar movements only.[1]

The following case report describes a camouflage therapeutic protocol in the management of a patient with severe skeletal class III malocclusion.

   Case History Top

Patient concern

A 22-year-old male patient reported to the Department of Orthodontics and Dentofacial Orthopaedics with a chief complaint of irregularly placed upper and lower front teeth.

Diagnostic aids

Extraoral examination revealed a normodivergent facial pattern, concave facial profile, deficient malar prominence and positive lip step. Intraoral examination revealed constricted maxillary arch with anterior crowding, missing 12, 13 and 22, retained deciduous 63, palatally placed 23 and severely retroclined mandibular incisors. The patient exhibited a bilateral Class III molar relationship. There was a deep overbite of 8 mm and a reverse overjet of 7 mm. Generalized anterior spacing was present with drifting of 11 and 21 into the edentulous space. The mandibular dental midline was shifted to the right side [Figure 1] and [Figure 2].
Figure 1: Pre-treatment records

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Figure 2: (a) Initial strap up and Arch expansion with Niti Palatal Expander. (b) Retraction phase

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Pretreatment Orthopantomogram (OPG) indicated an impacted 13, retained deciduous 63, congenitally missing 12, 22, 18, 28, 38 and 48 and restored 16 and 47.

The maxillary occlusal radiograph was taken for Canine impaction assessment using the criteria proposed by Power and Short and Stivaros and Mandalls. Angulation to midline was 20° (grade 2), Anteroposterior position of canine root apex was above the region of 1st premolar (grade 2), Vertical canine crown height was more than halfway up the root (Grade 3), Canine overlap of adjacent incisor root was less than half the root width (grade 2), No incisor root resorption was seen and 13 was palatally impacted which all confirmed that the canine was unfavourably positioned [Figure 1].

Cephalometric evaluation revealed skeletal class III with retrognathic maxilla and prognathic mandible on a relatively short cranial base and an average mandibular plane angle. The length of the maxilla was reduced and that of the mandible was increased. Lower anterior facial height was found to be normal due to vertical deficient maxilla which in turn caused over closure of the mandible. The upper incisors were proclined and the lower incisors were retroclined owing to severe dentoalveolar compensation. Holdaway angle (11°) and Wits appraisal (−6 mm) indicated it is a borderline case and can be managed by camouflage [Table 1].
Table 1: Comparison of pre- and post-treatment cephalometric variables

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An ideal treatment plan would include a combined orthodontic and conventional orthognathic surgery via Le Fort I maxillary advancement and genioplasty. After analysing the cost-risk-benefit, the patient refused to undergo surgery and chose orthodontic camouflage.

The finalized treatment plan was orthodontic camouflage by single incisor extraction 41 to reduce mandibular intercanine width, impacted 13 due to its unfavourable vertical position alongside removal of retained deciduous 63. Arch expansion via NiTi palatal expander and cuspidisation of 14, finally prosthodontic rehabilitation of the missing lateral incisors.

Orthodontic therapy was initiated with banding of maxillary first and second molar. Initially, maxillary arch was bonded using a Pre-Adjusted Edgewise prescription. Alignment and levelling were done sequentially. A lower posterior bite plate was used for unrestricted transverse correction. 0.036-inch lingual sheaths were welded over the first molar band and the preactivated NiTi palatal expander (45 mm) was assembled with bands as one unit for 3 months until considerable arch expansion had occurred. The same appliance was retained for 3 months for retention. Subsequently, 41 was extracted, and aligning and levelling of mandibular arch was carried out. The mandibular incisor brackets were inverted to induce positive torque conducive for retraction and thereby preventing cortical anchorage and recession. Retraction was completed using active lacebacks with 'V' bend between the incisors to prevent excessive tipping offering controlled movement. 14 was cuspidised for the impacted canine to restore canine substituted group function occlusion. Substitution of 43 to a lateral incisor was opted to achieve a coincident midline. Due to the long-standing edentulous space, the alveolar ridge was found to be inadequate to allow implant placement in 12 and 22 regions. Intentional RCT of 14, 11, 21 and 23 were carried out for prosthodontic replacement via a 6-unit metal ceramic Fixed Partial Denture. The entire treatment was completed in 22 months. Retention protocol with upper Begg's wrap around retainer and lower lingual bonded retainer was advocated for full time wear for 1 year [Figure 2] and [Figure 3].
Figure 3: Post-treatment records

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At the end of treatment, the patient had a pleasing smile and stable class III molar relationship with canine substituted occlusion and normal overbite and overjet ensuing anterior guidance and lateral excursions, thereby providing masticatory efficiency and maintaining TMJ integrity.

Superimposition of the pre and post orthodontic cephalometric tracing illustrates the associated dental and soft tissue changes [Figure 4], [Table 1].
Figure 4: Superimposition of pre and post-treatment cephalograms

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Follow up

The patient was monitored every 6 months post orthodontic treatment. In the 1 year of follow up, there was 0.5 mm midline discrepancy noted with no skeletal relapse [Figure 5].
Figure 5: 1 year follow up records

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   Discussion Top

Some of the discriminative factors to be considered for diagnosing a surgical and non-surgical case of class III are based on the envelope of discrepancy, Overbite, Overjet, Wits appraisal, ANB angle and lower incisor inclination. Holdaway angle greater than 10.3° and Wits appraisal greater than −5.8 mm could be treated by camouflage and this was in favour of the case.[1],[2]

Often class III camouflage involves proclining the maxillary and retroclining the mandibular anteriors under a safe biological limit with proclination of maxillary anteriors upto 120° to sella nasion line and mandibular anteriors retroclined up to 80° to mandibular plane.

The problem of restoring aesthetics in Class III malocclusion associated with missing maxillary lateral incisors can be confounding to resolve given the constriction of the maxillary arch and evidences that suggest agenesis is a strong predictor of maxillary canine impaction.[3]

Another major concern is the stability after mandibular incisor extraction.[4],[5] With retraction, the tongue occupies lesser space in the oral cavity due to reduced inter-canine width and resultant relapse may occur.[6] Thus, methods to improve stability need to be reinforced in the form of achieving ideal overjet and incisal stop, good intercuspation and permanent retainers.[4],[7],[8] Several studies have demonstrated the stability of skeletal Class III malocclusion treated by mandibular incisor extraction in maintaining the facial profile and incisor alignment.[9],[10]

In the present case, the maxillary space requirement was minimal and arch expansion via NiTi palatal expander was sufficient to mould the arch. Mandibular incisor extraction was done to reduce inter-canine width. An elective RCT was planned prior to fixed prosthetic procedure for teeth with presumed doubtful pulpal involvement and hypersensitivity, where in an extensive tooth preparation was involved to accommodate space for the lateral incisors. CBCT was not taken for confirmatory diagnosis as the implantologist clinically measured the alveolar bone. The patient refused to augment the alveolus since the procedure was time consuming and opted for a fixed partial denture.

Critical appraisal

In a class III molar occlusion, there is an overall decrease in the number of contact points between the two arches resulting in a weak occlusal equilibration thus the occlusion should be periodically monitored.

   Conclusion Top

The key to a successful orthodontic camouflage treatment lies in understanding the malocclusion, giving realistic treatment objectives and appropriate execution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Eslami S, Faber J, Fateh A, Sheikholaemmeh F, Grassia V, Jamilian A. Treatment decision in adult patients with class III malocclusion: Surgery versus orthodontics. Prog Orthod 2018;19:28.  Back to cited text no. 1
Martinez P, Bellot-Arcís C, Llamas JM. Orthodontic camouflage versus orthognathic surgery for class III deformity: Comparative cephalometric analysis. Int J Oral Maxillofac Surg 2017;46:P490-5.  Back to cited text no. 2
Tavajohi-Kermani H, Kapur R, Sciote J. Tooth agenesis and craniofacial morphology in an orthodontic population. Am J Orthod Dentofacial Orthop 2002;122:39-47.  Back to cited text no. 3
Moullas AT, Palomo JM, Gass JR, Amberman BD, White J, Gustovich D. Nonsurgical treatment of a patient with a Class III malocclusion. Am J Orthod Dentofacial Orthop 2006;129 (4 Suppl):S111-8.  Back to cited text no. 4
Chung KR, Kim SH, Choo H, Kook YA, Cope JB. Distalization of the mandibular dentition with mini-implants to correct a Class III malocclusion with a midline deviation. Am J Orthod Dentofacial Orthop 2010;137:135-46.  Back to cited text no. 5
Sugawara J, Daimaruya T, Umemori M, Nagasaka H, Takahashi I, Kawamura H, et al. Distal movement of mandibular molars in adult patients with the skeletal anchorage system. Am J Orthod Dentofacial Orthop 2004;125:130-8.  Back to cited text no. 6
Farret MM, Benitez Farret MM. Skeletal class III malocclusion treated using a nonsurgical approach supplemented with mini-implants: A case report. J Orthod 2013;40:256-63.  Back to cited text no. 7
Sobral MC, Habib FA, Nascimento AC. Vertical control in the class III compensatory treatment. Dental Press J Orthod 2013;18:141-59.  Back to cited text no. 8
Canut JA. Mandibular incisor extraction: Indications and long-term evaluation. Eur J Orthod 1996;18:485-9.  Back to cited text no. 9
Vignesh T, Senthil Kumar K P, Tamizharasi SK. Mandibular incisor extraction in orthodontics: A systematic review. J Indian Acad Dent Spec Res 2014;1:1-5.  Back to cited text no. 10
  [Full text]  

Correspondence Address:
Dr. Moina K Adeni
Opal Dentistry, 16-20, Wallace Garden 3rd Street, Thousand Lights, West Thousand Lights, Chennai - 600 006, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_551_20

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

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