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Pawankumar Dnyandeo Tekale et al 10.5005/jp-journals-10026-1136


REVIEW ARTICLE

Orthodontic Camouflage in Skeletal Class III Malocclusion:


A Contemporary Review
1
Pawankumar Dnyandeo Tekale, 2Ketan K Vakil, 3Jeegar K Vakil, 4Sameer Madhukarrao Parhad

ABSTRACT INTRODUCTION
Early orthopedic intervention can be effective in normalizing The developing skeletal class III malocclusion is one of
skeletal class III malocclusions if patients are treated in a timely
the most challenging problems confronting the practicing
manner. There are a large number of skeletal class III patients
that either decline or cannot afford surgical treatment. The only orthodontist. Early orthopedic intervention can be effective
alternative is ‘Orthodontic camouflage’ through comprehensive in normalizing skeletal class III malocclusion if patients
treatment with fixed appliances. The ultimate judgment as to are treated in a timely manner.1-6 Class III malocclusion is
whether orthodontic treatment alone, to camouflage a skeletal
a severe dentofacial anomaly. In most patients, there is no
problem, would be an acceptable result, or whether orthognathic
surgery to correct the jaw discrepancy would be required, must single feature responsible for the anomaly.7-14 Those with
be made by the patient and parents. Class III camouflage logically class III malocclusion frequently show combinations of
would be the reverse of class II camouflage, based on retracting skeletal and dentoalveolar components.15,16 Moreover, there
the lower incisors, advancing the upper incisors, and surgically
are complex interactions of genetic and environmental fac-
reducing the prominence of the chin, in addition, rotating the
mandible downward and backward, when the chin is prominent, tors that can act synergistically, in isolation, or in opposi-
can be considered a form of camouflage. Even though timing of tion.17,18 Compared with class I subjects, several aberrant
orthodontic treatment has always been somewhat controversial, cephalometric measurements have been reported in class
it is an agreement in the literature that prognosis is still obscure
III malocclusion patients, such as shorter anterior cranial
until growth is completed. A cephalometric analysis is needed
to quantitatively record the severity of the class III malocclusion base length, more acute cranial base angle, shorter and
and to determine the underlying cause of the deformity. Although more retrusive maxilla, more obtuse gonial angle, exces-
it is agreed that camouflage line of treatment is not an ideal line sive lower anterior face height, mandibular prognathism or
of treatment, but it serves its purpose very well in mild range
excessive growth, more proclined maxillary incisors, and
of skeletal dysplasia’s and in conditions where patient is either
unwilling for orthognathic surgery or in cases were surgery is more retroclined mandibular incisors.10-14 Studies have also
contraindicated. shown that no single morphologic feature indicates potential
Keywords: Orthodontic camouflage, Skeletal Class III, Adult class III development. Kerr et al19 presented cephalometric
treatment. criteria for classification of adult class III patients to treat
How to cite this article: Tekale PD, Vakil KK, Vakil JK, Parhad them objectively. The pretreatment lateral cephalograms of
SM. Orthodontic Camouflage in Skeletal Class III Malocclusion: patients who had either surgical or orthodontic treatment
A Contemporary Review. J Orofac Res 2014;4(2):98-102. of their class III malocclusion were compared by using
Source of support: Nil univariate statistical methods. Although significant differ-
Conflict of interest: None
ences were found between both groups in terms of ANB
angle, maxillary-mandibular (M/M) ratio, mandibular
incisor inclination and Holdaway’s angle, in view of the
1
Senior Resident, 2Professor and Head, 3Senior Lecturer complex interaction of skeletal and dentoalveolar parame-
4
Reader
ters, it seems highly improbable that single variables could
contain enough information to explain the anomaly.20 Fur-
1,3
Department of Orthodontics, SMBT Dental College and
Hospital, Sangamner, Maharashtra, India
thermore, univariate statistical techniques were insufficient
2
Diplomate of Indian Board of Orthodontics, Department of for diagnosis, treatment planning and outcome prognosis.21
Orthodontics, SMBT Dental College and Hospital, Sangamner
Maharashtra, India Therefore, recent studies have recommended a multivariate
4
Department of Orthodontics, Saraswati-Dhanwantari Dental
approach for analyzing the relationship between craniofacial
College, Parbhani, Maharashtra, India structure and class III malocclusion.22,23 Based on a discri-
Corresponding Author: Pawankumar Dnyandeo Tekale minant analysis (DA), Stellzig-Eisenhauer et al7 developed a
Senior Resident, Department of Orthodontics, SMBT Dental formula to classify class III adults into a group that is treat-
College and Hospital, Sangamner, Maharashtra, India, Phone: able solely orthodontically and a group that requires orthog
91-9970879100, e-mail: pawan0804@gmail.com
-nathic surgery. DA is a multivariate procedure that has

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Orthodontic Camouflage in Skeletal Class III Malocclusion: A Contemporary Review

been especially designed to differentiate between 2 groups WHAT IS CAMOUFLAGE?


of subjects from the same population.24 In the orthodontic
The word camouflage comes from a French word ‘camoufler’
literature, most studies with multivariate statistics explored
meaning ‘to blind or veil’. Camouflage means to disguise an
the potential of DA.25,26 The determining variables in the
object, in plain sight, in order to conceal it from something
aforementioned study were the following: Wits appraisal
and someone.
(Wits), length of the anterior base (S-N), M/M ratio, and
lower gonial angle (Go lower). With the multivariate model, CAMOUFLAGE IN ORTHODONTICS
92% of the study patients could be classified correctly.
Beyond the adolescence growth spurt, even though some
Consequently, the DA was highly significant (P\0.0001).
facial growth continues, too little remains to correct skeletal
In addition to these results, DA had previously been suc-
problem. The possibility of treatment therefore is either
cessfully applied to separate class III patients from class I
displacement of teeth relative to their supporting bone, to
subjects.22 Moreover, DA was used to determine the prog-
compensate for the underlying jaw discrepancy or surgi-
nosis for treatment outcome and relapse of orthodontically
cal repositioning of jaw. Camouflage treatment is defined
treated class III patients.23,27 In the study of Schuster et al,8
by Proffit28 as displacement of the teeth relative to their
multivariate procedures were used to identify the dentoskel-
supporting bone to compensate for an underlying jaw dis-
etal variables that provide the best differentiation between
crepancy. Thus, camouflage in orthodontics is defined as
prepubertal children with class III malocclusion who could
‘implementation of a less intensive treatment plan option in a
be adequately treated by orthopedic or orthodontic therapy
patient with a severe problem so as to obtain optimum results
alone and those who required orthognathic surgery. The
within physiologic limits and which may not be addressing
models were highly significant, classifying 93.2 to 94.3% of
the correction of the actually existing problem in the patient.’
the patients correctly. In the studies of Stellzig-Eisenhauer
Classification of camouflage is:
et al7 and Schuster et al,8 the Wits appraisal was the most 1. Orthodontic camouflage
predictive variable for differentiating between nonsurgery •  Class II camouflage
and surgery patients. However, the results of the former •  Class III camouflage
studies should be regarded critically. Although multivariate •  Camouflage of asymmetry
techniques are better than univariate ones, their limitations •  Camouflage of skeletal open bite
include the following: for a sufficiently stable model that 2. Surgical camouflage
also applies to patients outside the study, a large sample •  Chin surgery
size is a prerequisite, and the selection of parameters might •  Nasal surgery
not include all variables required to accurately differentiate •  Facial soft-tissue procedures
the groups.20,22,25 Stellzig-Eisenhauer et al7 could correctly •  Single jaw surgery in patient with double jaw problems
allocate 97.7% of the solely orthodontically treated adults Computer imaging in the decision for camouflage vs
with class III malocclusion. Those who required orthog- orthognathic surgery.28
nathic surgery could be classified in 86.4% of the cases; The ultimate judgment as to whether orthodontic treat-
only 2.3% of the nonsurgery patients were misclassified, ment alone, to camouflage a skeletal problem, would be an
but 13.6% of those who needed orthognathic surgery were acceptable result, or whether orthognathic surgery to correct
misclassified. These findings led to the hypothesis that, the jaw discrepancy would be required, must be made by
especially in borderline surgical patients, additional factors the patient and parents. The orthodontist’s role is to supply
are responsible for the necessity of surgical intervention. the information they need to make the decision and in that
Because class III patients frequently show skeletal devia- context, computer image predictions of the outcome without
tions in the transverse dimension, the predictive value of and with surgery are an important tool to help the patient and
the multivariate model might improve if transverse com- parents understand. For the doctor, there are two possible
ponents are included.7,8 However, there are a significant attitudes toward the use of computer predictions; this is dan-
group of patients who either do not have an opportunity to gerous because the predicted outcome may not be obtained,
receive early treatment or are corrected during childhood or this is excellent because it improves communication with
with significant relapse during the adolescent growth spurt. patients so that they really understand the options that are be-
In addition, there are a large number of skeletal class III ing offered. Patients appreciate the improved communication
patients that either decline or cannot afford surgical treat- that the computer predictions make possible, and compared
ment. The only alternative is ‘Orthodontic camouflage’ to those who did not see their predictions are more likely to
through comprehensive treatment with fixed appliances. be satisfied with the outcome of treatment.

Journal of Orofacial Research, April-June 2014;4(2):98-102 99


Pawankumar Dnyandeo Tekale et al

Class III Camouflage • Reasonably good alignment of teeth (so that the extrac-
tion spaces would be available for controlled anteropos-
Class III camouflage is more difficult than its class II
terior displacement and not used to relieve crowding).
counterpart, not because the tooth movement is more diffi-
• Good vertical facial proportions, neither extreme short
cult but because it is more difficult to obtain acceptable
face nor long face.
esthetics. The problem is that most class III patients already
have some dental compensation that developed during
Contraindications for Class III Camouflage
growth. Typically, the upper incisors are at least somewhat
Treatment28
proclined and protrusive relative to the maxilla, whereas
the lower incisors are upright and retrusive relative to the 1. Moderate or severe class III and vertical skeletal dis-
chin. Class III camouflage logically would be the reverse of crepancies.
class II camouflage, based on retracting the lower incisors, 2. Patients with severe crowding or protrusion of incisors,
advancing the upper incisors, and surgically reducing the in whom space created by extractions will be required
prominence of the chin, in addition, rotating the mandible to achieve proper alignment of the incisors.
downward and backward, when the chin is prominent, can 3. Adolescents with good growth potential (in whom
be considered a form of camouflage. The common problems growth modification should be tried first) or nongrow-
and difficulties in class III camouflage are listed in Table 1. ing adults with more than mild discrepancies (in whom
In order to correct an anterior crossbite, with orthodontics orthognathic surgery usually offers better long-term
alone, further protraction of the upper incisors and retraction results).
of the lower incisors would be necessary. As upper incisors 4. Medically compromised patients.
are tipped forward, their inclination becomes an esthetic 5. Mentally retarded patients.
problem, but torquing the roots forward is difficult and 6. Periodontally compromised patients.
stresses the anchorage. For all practical purposes, labial root 7. Need for immediate results (marriageable age).
torque to the upper incisors means that more retraction of
the lower incisors is necessary. That compounds the biggest Diagnostic Indicators in Class III Camouflage
problems with orthodontic camouflage; retracting the lower The differential diagnosis in skeletal class III malocclusions
incisors tends to accentuate the prominence of the chin, not plays a major role in the success of treatment results.
camouflage it. Unless the lower incisors are protrusive to Even though timing of orthodontic treatment has always
start with, little if any retraction is acceptable esthetically. been somewhat controversial, it is an agreement in the
Malocclusions with a mild mandibular prognathism literature that prognosis is still obscure until growth is
and a moderate overbite can be corrected by dentoalveolar completed. Variations in magnitude and expression of
movements. Class III elastics, with or without extraction class III malocclusion can present with some difficulty
of teeth, have been used to the camouflage the skeletal during diagnosis. For example, a patient may present with
discrepancy, resulting in an acceptable facial profile. Class
Table 1: Difficulties in class III camouflage
III cases with mild mandibular prognathism and crowding
Class III Orthodontic Limitation
can be treated by various extraction schemes including four
(Common Treatment
premolars (maxillary second premolars and mandibular first Problem)
premolars), two lower premolars (mandibular second or first Anterior cross Protraction of Further proclination
premolars) or a mandibular incisor.28 bite upper(u) incisors of upper incisors
becomes an esthetic
If this corrects the dental occlusion but does not cam- problem
ouflage the facial deformity, there are two possibilities for Retraction of Tends to accentuate
additional surgical camouflage; onlay grafts to the anterior lower(l) incisors the prominence of
chin
maxilla and reduction genioplasty. If there is a mandibular
Class III Extraction of lower Almost always
displacement between Cr and Co, this needs to be identified Malocclusion first premolar produces esthetically
and accurately recorded at the record taking appointment. undesirable results,
Displacements can be a major factor in determining a surgi- despite the good
occlusion achieved.
cal vs a nonsurgical decision for some patients.29 Chin is made more
prominent
Indications for Class III Camouflage Treatment28 Extraction of lower Difficult to close the
second premolar extraction spaces
• Too old for successful growth modification Extraction of one of Limited improvement
• Mild to moderate skeletal class III the lower incisors in anterior occlusion

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Orthodontic Camouflage in Skeletal Class III Malocclusion: A Contemporary Review

a combination of one or more dentofacial deformities, such proclined and protrusive relative to the maxilla, whereas
as true mandibular prognathism or maxillary retrognathism. the lower incisors are upright and retrusive relative to the
In order to differentiate the underlying cause of a class III chin. Class III camouflage logically would be the reverse of
malocclusion, a simplified method of evaluating patients class II camouflage, based on retracting the lower incisors,
must be utilized. Several authors have made the following advancing the upper incisors, and surgically reducing the
recommendations in the assessment of class III patients. prominence of the chin, in addition, rotating the mandible
First, it is important to question both the patient and his/ downward and backward, when the chin is prominent, can
her parents about the presence of a large jaw or anterior be considered a form of camouflage.28
crossbite among their family members. If a close relative In order to correct an anterior crossbite, with orthod-
required orthognathic surgery, this should alert the clinician ontics alone, further protraction of the upper incisors and
to the probability that the patient under examination may retraction of the lower incisors would be necessary. As upper
also exhibit a severe skeletal discrepancy. Second, assess the incisors are tipped forward, their inclination becomes an
presence of a functional shift. The relationship of maxilla esthetic problem, but torquing the roots forward is difficult
to mandible should be evaluated to determine whether a and stresses the anchorage. For all practical purposes, labial
discrepancy exists between centric relation and centric root torque to the upper incisors means that more retraction
occlusion. Anterior repositioning of the mandible may be of the lower incisors is necessary. That compounds the
due to abnormal tooth contact that forces the mandible biggest problems with orthodontic camouflage; retracting
forward. These patients tend to present with a class I skeletal the lower incisors tends to accentuate the prominence of
pattern, normal facial profile and class I molar relation in the chin, not camouflage it. Unless the lower incisors are
centric relation, but a class III skeletal and dental pattern in protrusive to start with, little if any retraction is acceptable
centric occlusion. Early correction of this ‘pseudo’ class III esthetically.
condition may provide for a more favorable environment for Malocclusions with a mild mandibular prognathism
future growth. Third, a panoramic and lateral cephalometric and a moderate overbite can be corrected by dentoalveolar
radiograph is required to complete the diagnosis and assist movements. Class III elastics, with or without extraction
the clinician in treatment planning. A cephalometric analysis of teeth, have been used to the camouflage the skeletal
is needed to quantitatively record the severity of the class discrepancy, resulting in an acceptable facial profile. Class
III malocclusion and to determine the underlying cause of III cases with mild mandibular prognathism and crowding
the deformity. Common predictors of successful class III can be treated by various extraction schemes including four
camouflage used to evaluate the maxillary and mandibular premolars (maxillary second premolars and mandibular
position include first premolars), two lower premolars (mandibular second
• ANB-(less than -2 to -3 mm) or first premolars) or a mandibular incisor.9 If this corrects
• Wits appraisal ( -2 to -6 could be treated nonsurgically) the dental occlusion but does not camouflage the facial
• Linear measurements of Condylion to A point and Con- deformity, there are two possibilities for additional surgi-
dylion to Gnathion, cal camouflage; onlay grafts to the anterior maxilla and
• Percentage of midfacial length/mandibular length ratio reduction genioplasty.
(Co-A/Co-Gn) If there is a mandibular displacement between centric
• The net sum difference between maxillary and mandi- relation and centric occlusion, this needs to be identified
bular lengths, the mandibular ramus height/mandibular and accurately recorded at the record taking appointment.
body length ratio, and the gonial angle. Lastly, clinical Displacements can be a major factor in determining a surgi-
assessment may be the most important evaluation for cal vs a nonsurgical decision for some patients.4
the diagnosis when the objective of treatment planning There are several methods of conventional cephalomet-
is to optimize facial esthetics. ric analyses to assess A/P skeletal discrepancy. The Arnett
analysis uses a true vertical line as a facial reference and
CAMOUFLAGE TREATMENT OF
it is recommended as a more sophisticated and accurate
SKELETAL CLASS III
method of deciding the needs of the case.
Class III camouflage is more difficult than its class II Class III patients with mild to moderate class III skeletal
counterpart, not because the tooth movement is more diffi- patterns with a growth treatment response vector (GTRV)
cult but because it is more difficult to obtain acceptable ratio between 0.33 and 0.88 can be successfully camouflaged
esthetics. The problem is that most class III patients already with orthodontic treatment. Class III patients with excessive
have some dental compensation that developed during mandibular growth and a GTRV ratio below 0.38 should be
growth. Typically, the upper incisors are at least somewhat warned of the need for future orthognathic surgery.30
Journal of Orofacial Research, April-June 2014;4(2):98-102 101
Pawankumar Dnyandeo Tekale et al

CONCLUSION 12. Schulhof RJ, Nakumara S, Williamson WV. Prediction of


abnormal growth in class III malocclusions. Am J Orthod 1977
Although we all agree that camouflage line of treatment is Apr;71(4):421-430.
not an ideal line of treatment, but it serves its purpose very 13. Troy BA, Shanker S, Fields HW, Vig K, Johnston W. Compari-
well in mild range of skeletal dysplasia’s and in conditions son of incisor inclination in patients with Class III malocclusion
treated with orthognathic surgery or orthodontic camouflage.
where patient is either unwilling for orthognathic surgery Am J Orthod Dentofacial Orthop 2009 Feb;135(2):146.e1-9.
or in cases were surgery is contraindicated. In these cases 14. Chang HP, Liu PH, Yang YH, Lin HC, Chang CH. Craniofacial
camouflage treatment serves as a blessing because it helps morphometric analysis of mandibular prognathism. J Oral
the orthodontist to enhance patient’s self-esteem, esthetics Rehab 2006 Mar;33(3):183-193.
15. Mackay F, Jones JA, Thompson R, Simpson W. Craniofacial
and function. However, proper diagnosis and the establish- form in class III cases. Br J Orthod 1992 Feb;19(1):15-20.
ment of realistic treatment objectives by the clinician and the 16. Ngan P, Hagg U, Yiu C, Merwin D, Wie SH. Cephalometric
patient are necessary to prevent undesirable sequel in cam- comparisons of Chinese and Caucasian surgical Class III
ouflaging a mild to moderate skeletal class III malocclusion. patients. Int J Adult Orthod Orthognath Surg 1997;12(3):177-188.
17. Ellis E 3rd, McNamara JA Jr. Components of adult Class III
malocclusion. J Oral Maxillofac Surg 1984 May;42(5):295-305.
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