© 2018 APOS T ends in O hodon ics | Published by Wol e s Kluwe - Medknow 161
Add ess o co espondence:
D . Juan Ca los Pé ez Va ela,
C/Dou o Teixei o N 12 1,
15701, San iago De Compos ela,
A Co uña, Spain.
E‑mail: jcpe [email p o ec ed],
clinicadelno [email p o ec ed]
Access his a icle online
Websi e:
www.apospublica ions.com
DOI: 10.4103/apos.apos_63_18
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Class III malocclusions a e conside ed o be one o he mos di icul p oblems o ea . Due o he
signi ican numbe o pa ien s wi h Class III malocclusion who canno unde go o hogna hic su ge y
o di e en easons, we ha e p oposed an al e na i e ea men ha we ha e called su gically
assis ed apid pala al expansion (SARPE) + empo a y ancho age de ices (TADs) which allows
sol ing mild and mode a e Class III malocclusion combined wi h maxilla y comp ession, ob aining
accep able es he ic and unc ional esul s. We p esen a case epo o an adul emale wi h skele al
Class III malocclusion wi h comp ession in he maxilla y and mandibula asymme y, who was
ea ed wi h SARPE + TADs. The esul is accep able in e ms o occlusion unc ion, es he ic o he
smile, and acial es he ics.
Keywo ds: Case epo , Class III malocclusion, maxilla y comp ession, o hodon ics, su gically
assis ed apid pala al expansion + empo a y ancho age de ices
Skele al Class III Malocclusion in an Adul Pa ien – O hodon ics e sus
O hogna hic Su ge y: Is he e Ano he Al e na i e?
Case Repo
Juan Ca los Pé ez
Va ela,
Bea iz Iglesias
Sánchez,
Mi iam López Vila
Depa men o O hodon ics,
Uni e si y o San iago de
Compos ela, Galicia, Spain
How o ci e his a icle: Pé ez Va ela JC, Sánchez BI,
Vila ML. Skele al class III malocclusion in an adul
pa ien – o hodon ics e sus o hogna hic su ge y:
Is he e ano he al e na i e? APOS T ends O hod
2018;8:161-7.
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Fo ep in s con ac : ep in [email protected]
In oduc ion
Acco ding o he classi ica ion o D . Angle,
Class III is he malocclusion in which he
es ibula g oo e o he lowe i s mola is
loca ed mesial o he mesiobuccal cusp o
he uppe i s mola .[1]
I is necessa y o dis inguish a den al
Class III malocclusion om skele al one
because in he second, he malocclusion is
due o a disp opo ion in he bony bases,
which may be due o a e ogna hism o he
uppe jaw, a mandibula p ogna hism, o a
combina ion o bo h.[2,3]
The highes p e alence o Class III
malocclusions is ound in Asia (12%) and
Eu ope, alues anging be ween 1.5% and
5.3% and in Caucasians in No h Ame ica
be ween 1% and 4%.[4,5]
The skele al de o mi ies a e he esul o he
p esence o anomalies in he posi ion o he
maxilla and mandible. In malocclusions in
which a single bone is in ol ed, maxilla y
e usion is mo e common (19.5%) han a
mandibula p o usion (19.2%), al hough he
p esence o hese wo ea u es in a combined
o m is mo e common (30.2%).[6,7]
In he ea men o skele al Class III
malocclusion in adul s, he e a e basically
wo ea men al e na i es: o hodon ic
ea men and su gical ea men combined
wi h o hodon ics. The choice o one o
he o he will depend on se e al ac o s;
one o he main ones will be he deg ee
o bone disc epancy, since o hodon ic
camou lage can only be done when Class III
malocclusion is mild. On he o he hand, no
all pa ien s a e willing o unde go su gical
ea men , due o i s cos , in asi e na u e,
o heal h condi ions, despi e being he ideal
op ion om he o hodon ic poin o iew.[8‑10]
In cases in which, in addi ion o he sagi al
p oblem, he e is a ans e sal p oblem due
o maxilla y comp ession, i is possible o
pe o m a segmen ed Le Fo (combining
Le Fo I wi h os eo omies ha allow
disjunc ion). Ano he op ion is he p e ious
execu ion o a su gically assis ed apid
pala al expansion (SARPE).[11‑13]
Fede ico He nández Al a o desc ibes he
SARPE pe o med on 257 pa ien s, unde
local anes hesia and seda ion, making a
comple e Le Fo I wi hou mobiliza ion,
which achie es a o al elease and
bipa i ion o he maxilla ha gua an ees
skele al dis ac ion and p e en s a damaging
load a he den al le el.[14]
Due o he numbe o pa ien s wi h
Class III malocclusion wi h maxilla y
Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
162 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018
Figu e 1: Ini ial ex ao al pho og aphs
Figu e 2: Ini ial in ao al pho og aphs
Figu e 3: Ini ial ele adiog aph and o hopan omog aphy
Figu e 4: Cone beam compu ed omog aphy be o e su gically assis ed
apid pala al expansion
comp ession who e use ea men wi h o hogna hic
su ge y, we ha e p oposed a less in asi e solu ion o he
pa ien , mo e economically a o dable, and ha ob ains
e y good esul s, bo h es he ically and unc ionally.
This al e na i e consis s in he pe o mance o a SARPE
unde local anes hesia and seda ion, and he placemen o
minipla es, wo supe io s a he le el o he p e ygoid and
wo in e io s in he symphysis, be ween he la e al inciso s
and he canines.
The case p esen ed is a Class III malocclusion wi h
maxilla y comp ession, mandibula asymme y, and
de ia ion o he lowe line o he igh .
Al hough he ideal op ion o co ec all he p oblems was
o hogna hic su ge y, he pa ien decided o unde go ea men
o SARPE + empo a y ancho age de ices (TADs), assuming
ha he mandibula asymme y would no be co ec ed.
Diagnosis and e iology
The pa ien is an adul o 28 yea s old p esen ing wi h
ans e sal and sagi al hypoplasia o he maxilla, skele al
asymme y, de ia ion o he lowe line o he igh , and
c owding.
Clinical on al examina ion e ealed an asymme ical
ace. The p o ile assessmen e ealed conca e p o ile,
wi h an e io acial di e gence, la cheekbone con ou ,
and pu e es he ics o he smile in he on al and la e al
iews [Figu e 1]. When we analyzed he smile in de ail,
we obse ed c owding, poo coo dina ion o he den al
midlines, and he uppe ee h a e wo n [Figu e 1].
In ao al examina ion e ealed Class III mola and canine
ela ion on bo h sides. The mandibula midline was
de ia ed 4.5 mm o he igh . The pa ien had uppe and
lowe c owding and comp ession in he maxilla [Figu e 2].
Tempo omandibula join (TMJ) examina ion e ealed
a li le disc epancy be ween cen ic ela ion and cen ic
occlusion, and he pa ien complained o pain in he
join .
Cephalome ic examina ion e ealed e ogna hic maxilla
(SNA 73º) and Class III malocclusion (Wi s ‑10mm and
ANB ‑4º) [Figu e 3 and Table 1].
T ea men p og ess
Due o he la ge numbe o adul pa ien s who p esen
Class III malocclusion bu decide no o unde go o hogna hic
su ge y, despi e being he ideal op ion, o di e en easons
explained abo e, we decided o de ise an in e media e
op ion be ween camou lage and o hogna hic su ge y.
When a SARPE is pe o med o sol e maxilla y
comp ession, he pala ine and p e ygoid su u es a e
eleased. I we also add some minipla es a he le el o he
Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 163
p e ygoids each side by es ibula and o he s be ween he
lowe la e al inciso s and he lowe canines by es ibula ,
we can pull o wa d he maxilla, bene i ing om he
elease o he p e ygoid su u es made in he SARPE. We
ha e de ined his echnique as SARPE + TADs.
O hodon ic ea men combined wi h SARPE + TADs
consis s o h ee phases: p esu gical o hodon ic ea men ,
su gical ea men , and pos su gical o hodon ic ea men .
Table 1: Cephalome ic alues
Value Mean Ini ial T ea men
p e‑SARPE
Final
SNA (º) 82±3.5 73 73 76.5
SNPg (º) 80±3.5 77 77 77
SNB (º) 80±2 77.5 77.5 77.5
ANPg (º) 2±1.5 −4.5 −4.5 −1
ANB (º) 2±1 −4 −4 −0.5
SN/ANS‑PNS (º) 8±3.0 14.5 14.5 14.5
SN/GoGn (º) 33±2.5 38 38 38
ANS‑PNS/GoGn (º) 25±6.0 20 20 20
+1/ANS‑PNS (º) 110±6.0 108 108 119.5
−1/GoGn (º) 94±7.0 83 91 82
O e je (mm) 3.5±2.5 −0.3 −2 0.3
O e bi e (mm) 2±2.5 1.7 1.5 2
In e incisal (º) 132±6.0 147 142 137
Wi s 0±1 −10 −10 −4
SARPE: Su gically assis ed apid pala al expansion
Figu e 5: Tele adiog aph be o e su gically assis ed apid pala al expansion
Figu e 7: In ao al pho og aphs be o e su gically assis ed apid pala al expansion
Figu e 8: Ex ao al pho og aphs a e su gically assis ed apid pala al expansion
Figu e 6: Ex ao al pho og aphs be o e su gically assis ed apid pala al expansion
Figu e 9: In ao al pho og aphs a e su gically assis ed apid pala al expansion
Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
164 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018
Figu e 10: Cone-beam compu ed omog aphy a e maxilla y expansion
Figu e 11: In ao al pho og aphs du ing he ea men
Figu e 12: Final ex ao al pho og aphs
Figu e 13: Final in ao al pho og aphs
Figu e 14: Final in ao al scan
(CBCT) o measu e he ans e sal p oblem [Figu es 4 and 5].
The pa ien i s needed a su ge y o expand he maxilla y
by SARPE echnique be o e he placemen o b acke s in
he uppe a ch. In ou p o ocol, his su ge y is conside ed
ambula o y because i is pe o med unde local anes hesia and
seda ion on an ou pa ien basis in 30 min [Figu es 6‑9].
Nex , he pa ien unde wen he ope a ion o
SARPE + TADs. The ac i a ion was 3 u ns pe day, and
an in e maxilla y elas ic was placed om he igh uppe
minipla e o he lowe igh one and ano he om he uppe
le minipla e o he lowe le one, wi h o ces o 200–400 g
pe side o app oxima ely 24 h a day ( he pa ien can only
emo e hem o ea and b ush he ee h) [Figu e 8].
Once he desi ed expansion was ob ained, we made a CBCT
o con i m ha he expansion was comple ely co ec ed and
o measu e he sagi al ad ance o he maxilla [Figu e 10].
One mon h la e o he las u n o he sc ew, we
bonded he b acke s in he uppe a ch and we closed he
dias ema and coo dina ed he den al a ches o achie e an
In pa ien s wi h skele al p oblems and TMJ pain, we
p opose o use a spli in uppe a ch, and we decompensa e
he lowe a ch o make su e which is he eal ans e sal
and sagi al p oblem o 4 mon hs.
A e his i s phase, we did a ele adiog aph
[Figu e 4 and Table 1] and a cone‑beam compu ed omog aphy
Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 165
Figu e 15: Final cone-beam compu ed omog aphy
Figu e 16: Final ele adiog aph
Figu e 17: Supe posi ion o he acings be o e su gically assis ed apid
pala al expansion (blue) and inal ( ed) on he an e io c anial base
adequa e occlusion and es he ics o he smile ( o cen e
he midlines, ob ain mola and canine in Class I, achie e
o e bi e wi h in e maxilla y elas ics, and ge a co ec
smile a ch) [Figu e 11]. The elas ics o he minipla es
con inued o be placed un il he pa ien ’s sagi al p oblem
was esol ed.
Du ing he ea men , we used he ollowing a ches:
• Alignmen : 0.014 NiTi and 0.016 NiTi
• Le eling: 0.017 × 0.025 NiTi.
• To que and space closu e: 0.019 × 0.025 s eel wi e
• Finishing: 0.018 s eel wi e wi h bindings.
T ea men esul s
A e he ea men , he b acke s and TADs we e emo ed
and inal adiog aphs we e aken.
The esul a e he ea men is accep able. We ob ained
a signi ican imp o emen in alignmen , occlusion
unc ion, coo dina ion o he midlines, and es he ics o
he smile in on al and la e al iews and acial es he ics.
The mandibula asymme y was no co ec ed since
o hogna hic su ge y would ha e been necessa y o his
pu pose [Figu es 12 and 13].
The lingual occlusion is accep able, and we can see i wi h
he den al scan [Figu e 14].
In he CBCT, we can obse e ha he oo s a e in
he middle o he al eola bone, and he e is no oo
eso p ion [Figu e 15].
Cephalome ic examina ion showed an ad ance o he
maxilla (SNA 76.5º), a Class I malocclusion (Wi s ‑4
and ANB ‑0.5º) and a co ec in e incisal angle (137º)
[Figu e 16 and Table 1].
The main changes ob ained in he ea men o
SARPE + TADs in he pa ien a e as ollows [Table 1]:
• The e ha e been no o a ions o he maxilla y o
mandibula plane
• The Class III malocclusion has been comple ely
co ec ed (ANB om −4º o −0.5º, Wi s om −10
o −4 mm)
• P ope ad ancemen o maxilla has been achie ed
(SNA om 73º o 76.5º)
• The inclina ion o he uppe inciso (119.5º) and he
lowe (92º) is co ec ed
• The in e incisal angle is co ec ed (137º)
• The o e je dec eased om ‑2 o 0mm.
In o de o isualize he changes p oduced a e he
ea men o he pa ien wi h SARPE + TADs, he
supe posi ion o he acings a e SARPE and inal,
on he an e io c anial base, was made, showing all he

Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
166 APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018
Figu e 19: Compa ison be ween ini ial and inal in ao al pho og aphs
Figu e 18: Compa ison be ween ini ial and inal ex ao al pho og aphs
Figu e 20: Re en ion ex ao al pho og aphs
changes p e iously exposed [Figu e 17], and a compa ison
be ween in ao al and ex ao al pho og aphs was made
[Figu es 18 and 19].
Two yea s la e , he occlusion unc ion is s able. The
es he ic o he smile is accep able. The pa ien does no
ha e TMJ p oblems [Figu es 20 and 21].
Conclusion
In cases whe e he e a e a maxilla y comp ession and a
mild o mode a e Class III malocclusion, and/o when he
pa ien ejec s he op ion o o hogna hic su ge y due o i s
economic cos , heal h condi ions, o in asi e na u e, he
ea men o SARPE + TADs is an op ion ha ob ains e y
Va ela, e al.: Skele al Class III Malocclusion in an Adul Pa ien -O hodon ics e sus O hogna hic Su ge y: Is he e Ano he Al e na i e?
APOS T ends in O hodon ics | Volume 8 | Issue 3 | July-Sep embe 2018 167
Figu e 21: Re en ion in ao al pho og aphs
accep able esul s, bo h unc ionally and es he ically, and
allows pa ien s o sol e skele al p oblems ha un il now
could only be co ec ed wi h o hogna hic su ge y.
Decla a ion o pa ien consen
The au ho s ce i y ha hey ha e ob ained all app op ia e
pa ien consen o ms. In he o m, he pa ien has gi en
his consen o he images and o he clinical in o ma ion
o be epo ed in he jou nal. The pa ien unde s ands ha
he names and ini ials will no be published and due e o s
will be made o conceal he iden i y, bu anonymi y canno
be gua an eed.
Financial suppo and sponso ship
Nil.
Con lic s o in e es
The e a e no con lic s o in e es .
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