Orthodontic Camouflage: A Treatment Option - A Clinical Case Report.

Orthodontic camouflage provides an alternative treatment for angle III malocclusion since patients with limited economic resources cannot opt for orthognathic surgery, it being clear that correction will be achieved at the dental level and not at the bone complex.
OBJECTIVE: To determine an alternative treatment for patients who do not have the possibility of having orthognathic surgery. CLINICAL CASE: A 13-year-old female patient, dolico facial biotype with slightly concave profile, with Class III Skeletal by mandibular prognathism, anterior crossbite, anterior diastema, and large mandibular body, molar class, and canine III. Alexander technique brackets were placed; premolar extraction was not planned. Once the case was completed, the correction of the anterior crossbite was achieved, thanks to the use of the spaces that existed at the beginning of the treatment and also that a correct distalization of canines and retraction of the lower anterior segment were performed.

Introduction

Skeletal malocclusion occurs when there is predisposition in the size or position of the jaws. Skeletal Class III is one of the most common bone abnormalities in patients attending the orthodontic clinic. This occurs in patients who have shown a greater growth of the mandible compared to the maxilla, altering the facial profile, molar, and canine relations, and in other cases affects the masticatory functions.[1]

The etiology of a malocclusion can be due to many factors, which may include occlusal forces, inheritance, unfavorable growth patterns, systemic diseases, or oral habits such as digital sucking, lingual interposition, mouth breathing among others, causing swallowing alterations, speech, chewing, and above all affects the esthetics of the patient.[23]

Proffit points out three treatment possibilities for patients with such skeletal characteristics:

Modification of growth

Camouflage of the skeletal maxillary discrepancy

Orthognathic surgery.[4]

Orthodontic camouflage is a viable alternative for the treatment of mild-to-moderate skeletal discrepancies of the maxillary structures; the therapeutic objective is to correct the malocclusion while trying to disguise the skeletal problem.[5]

The objective of this research is to provide an alternative work for orthodontic professionals for those patients who present a Class III Skeletal, and don’t have the economic sources to pay for an orthodontic-surgical treatment.

At the end of the treatment, the initial goals of the treatment were achieved, such as improving the patient's profile, obtaining functional molar class and canine Class I, correcting cross-bite, and improving overbite and overjet.

Case Report

A 13-year-old female patient visits the orthodontic consultation with a normal medical history and without a family medical history, without medication allergy. In the extraoral photos, a facial biotype was presented, with a slightly concave straight profile [Figure 1].

Figure 1

Before treatment. Extraoral photo of front, extraoral right profile, cephalometric analysis, intraoral photo of right, front, and left

In the intraoral photos, we can observe a coincident midline, anterior diastema in the upper and lower arch, anterior crossbite, molar and canine Class III [Figure 1].

In the orthopantomograms, the third molars in formation process and eruption with bad position can be observed. The presence of spaces in the lower anterior sector is shown in Figure 2.

Figure 2

Orthopantomograms before and after

In the cephalometric analysis of Jarabak, the patient presented Class III skeletal by mandibular prognathism, a horizontal growth type, maxillary dentoalveolar proclination, biretroquelia, and a large mandibular body [Figure 3].

Figure 3

Ceph Rx and tracings before and after

The treatment plan was to align and level, closure of spaces, distalization of lower canines, retraction of the lower anterior segment, a possible therapy with Class III ligatures, lower posterior stripping if necessary, paralleling roots and containment with superior circumferential Hawley and fixed 3 to 3 lower.

The orthodontic camouflage treatment was performed in the growth stage (13 years) since the patient and her parents did not agree with the use of extraoral devices; in addition, they stated that they did not have the economic resources to pay for orthognathic surgery in future. That is why we sought the most convenient option for the patient at that time.

The prognosis of the case was favorable since the patient presented spaces in the anterior sector, which allowed to avoid extractions of premolars and thus to be able to perform the treatment with orthodontic camouflage.

We worked with the Alexander technique with slot 022 brackets. Initial and lower initial 0.012 arches were placed on July 30, 2012. After the distalization of lower canines on January 7, 2013, we proceeded to place a 0.016 × 0.016 upper arch and a simple retraction arch in 0.016 × 0.016 lower steel [Figure 4].

Figure 4

During treatment. Intraoral photo of right, front, and left

By April 1, 2013, total retraction of the lower anterosegment had been achieved, proceeding to place a 0.016 × 0.022 steel bow and mooring with molar to molar metal ligation to avoid opening of spaces. In the upper jaw was placed an arch of 0.017 × 0.025 niti, in addition to a chain of 11–21 for closing diastema.

Once the diagnosis of skeletal Class III with crossbite and horizontal growth of the patient was determined, once the distalization of canines was achieved, the anterior sector was retracted. This allowed, together with the use of Class III intermaxillary ligatures, to redirect the mandibular growth of the 13-year-old patient. It is necessary to remember that a solution of the problem (previous crossed bite) of the patient should be sought, due to the few financial resources of her parents to plan future orthognathic surgery.

For July 08, 2013, stripping was carried out in the right lower posterior sector, to gain space and achieve correction of the lower midline; in addition, a league of 1/8 median was placed in a triangle of 23 a 33–34 to obtain a correct intercuspation.

The treatment of orthodontics was completed on December 11, 2013. Below are the final photos and their comparisons with the initials. It can be noticed that the facial biotype (Dólico) has not varied with the treatment of orthodontics [Figure 5].

Figure 5

After treatment. Extraoral photo of front, extraoral right profile, cephalometric analysis, intraoral photo of right, front, and left

The cross bite present at the beginning of treatment could be corrected correctly. In addition, a good alignment of the teeth was achieved and a slight deviation of the upper middle line. The molar classes continued in III but functional and Class I left canine and right canine Class III were obtained [Figure 3].

In the lateral radiograph of the skull, as well as in the cephalometric tracing after treatment, we can see that the mandibular prognathism persists, with an ANB angle of −3, proclination of the upper teeth and slight retroclination of the lower ones, besides continuing with a growth in the horizontal direction [Figure 3].

Discussion

The treatment of a skeletal Class III by means of orthodontic camouflage will always create controversy among specialists since it must have a clear knowledge about the pros and cons of this option of treatment for the patient, who should be very clear about the consequences of the application of camouflage compared to orthognathic surgery.

For Mihalik and Proffit, the most important decision between camouflage or surgery should be based on the question of whether the dentofacial esthetic improvement achieved with surgery is worth the increase in the cost of the treatment and the risk it represents for the patient. The risks of surgery may obviously be much greater than those presented in patients treated with camouflage.[6]

The present case, in addition to presenting a discrepancy in growth between the maxillary and mandibular, provided the advantage of having spaces in the lower arch as diastemas, which avoided extractions of lower premolars and facilitated the application of the mechanics of previously planned treatment for this case.

In a study by Burns, Musich, Martin, Thomas Razmus, and Ngan, 30 patients with a 12-year deviation of 1 year with Class III malocclusion who had completed their orthodontic treatment determined skeletal, dental, and soft tissue changes, which resulted in the sagittal intermaxillary relationship (ANB angle) not improved with orthodontic treatment of camouflage.[7]

In this research, it can be seen that the ANB angle continues to mark a skeletal Class III, although it was possible to decrease from −4 to −3 said angle, and it was possible to reduce teeth inclinations from 2 to 3 degrees. In addition, the rest of skeletal angles did not vary.

At the end of the case, the correction of the anterior crossbite was achieved, thanks to the fact that the spaces that existed at the beginning of the treatment were taken advantage of and that distalization of canines and retraction of the lower anterior segment were performed in a good way.

The vestibularization of the lower anterior parts was controlled, thanks to the cinching of the titanium and steel nickel arches that were used throughout the treatment, with the aim of not losing the spaces existing at the beginning of the case and to correct the bite.

Patients who present a marked skeletal Class III, both at the facial profile level and in the cephalometric analyses, should be referred to the maxillofacial surgeon to perform a joint assessment with the orthodontist on the case. This will determine the best treatment option for the patient.

In order to be able to perform orthodontic treatment to compensate for slight discrepancies in the jaws, a correct diagnosis must be made and an adequate treatment plan was developed for the patient, which will yield excellent results for the patient. Orthodontist, leaving the patient free to undergo a surgical treatment, which entails a high economic expense and the risks inherent in a maxillofacial surgery.[89]

Once the surgical option was discarded within the present case, it was proposed to use an orthodontic treatment that was accompanied by oral rehabilitation since restorations and veneers were performed to improve the occlusion of the patient. The orthodontist must control and perform correctly the mechanics of the treatment since in the cases by means of camouflage can be more complicated without having the necessary knowledge, causing a prejudice to the patient.

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

Nil.

Conflicts of interest

There are no conflicts of interest.