Treatment Decision for Borderline Class III Malocclusion in Adults; Orthodontic Camouflage versus Orthodontic Orthognathic Surgery
Objectives: Determining the optimal treatment approach for adult borderline Class III malocclusion, whether orthodontic camouflage or orthodontic-orthognathic surgery, remains clinically challenging. This study aimed to distinguish between these two treatment options using lateral cephalometric analysis.
Methods: Pretreatment lateral cephalograms of 60 adult patients with borderline Class III malocclusion were analyzed, comprising 30 patients in the camouflage group and 30 in the surgery group. The Mann-Whitney U test was used to compare cephalometric variables between the two groups. Stepwise discriminant analysis was employed to identify the variables that best differentiated the treatment groups. An equation was then generated using the canonical discriminant function coefficients of the selected variables and a constant to calculate a critical score for treatment categorization.
Results: Stepwise discriminant analysis identified four key variables and generated the following equation: Individual score = –13.684+0.138(SN)+0.312(Wits)+0.068 (L1-MP)+0.179(H angle). A critical score of 0 was established. Patients with scores above 0 were considered suitable for orthodontic camouflage, while those with scores below 0 were better suited for orthodontic-orthognathic surgery. The overall classification accuracy of the model was 86.7%.
Conclusions: Four cephalometric variables including SN length, Wits appraisal, L1-MP angle, and H angle were effective in distinguishing appropriate treatment modalities for adult borderline Class III malocclusion patients.
1. Zere E, Chaudhari PK, Sharan J, Dhingra K, Tiwari N. Developing Class III malocclusions: challenges and solutions. Clin Cosmet Investig Dent. 2018;10:99-116.
2. Li C, Cai Y, Chen S, Chen F. Classification and characterization of class III malocclusion in Chinese individuals. Head Face Med. 2016;12(1):31.
3. Rabie AB, Wong RW, Min GU. Treatment in Borderline class III malocclusion: orthodontic camouflage (extraction) versus orthognathic surgery. Open Dent J. 2008;2:38-48.
4. Vasconcelos MB, Pinzan-Vercelino CR, Gurgel JD, Bramante FD. Cephalometric characteristics of class III malocclusion in Brazilian individuals. Braz J Oral Sci. 2014;13(4):314-8.
5. 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(1):28.
6. Varela JP, Vila M. Skeletal class III malocclusion in an adult patient-orthodontics versus orthognathic surgery: is there another alternative?. APOS Trends Orthod. 2018;8(3):161.
7. Benyahia H, Azaroual MF, Garcia C, Hamou E, Abouqal R, Zaoui F. Treatment of skeletal class III malocclusions: orthognathic surgery or orthodontic camouflage? how to decide. Int Orthod. 2011;9(2):196-209.
8. Stellzig-Eisenhauer A, Lux CJ, Schuster G. Treatment decision in adult patients with class III malocclusion: orthodontic therapy or orthognathic surgery?. Am J Orthod Dentofacial Orthop. 2002;122(1):27-37.
9. Kochel J, Emmerich S, Meyer-Marcotty P, Stellzig-Eisenhauer A. New model for surgical and nonsurgical therapy in adults with class III malocclusion. Am J Orthod Dentofacial Orthop. 2011;139(2):e165-74.
10. Galvão MC, Sato JR, Coelho EC. Dahlberg formula: a novel approach for its evaluation. Dental Press J Orthod. 2012;17:115-24.
11. Lo Giudice A, Rustico L, Ronsivalle V, Spinuzza P, Polizzi A, Bellocchio AM, et al. A full diagnostic process for the orthodontic treatment strategy: a documented case report. Dent J (Basel). 2020;8(2):41. doi: 10.3390/dj8020041.
12. Rheude B, Sadowsky PL, Ferriera A, Jacobson A. An evaluation of the use of digital study models in orthodontic diagnosis and treatment planning. Angle Orthod. 2005;75(3):300-4.
13. Sivarajan S, Zakaria NN, Azmily N, Wey MC, Abd-ElGhafour Omar M, Fayed M. Determination of treatment options for class III malocclusions in adult patients based on cephalometric values: a systematic review. Aust Orthod J. 2022;38:183-93.
14. Durão AR, Alqerban A, Ferreira AP, Jacobs R. Influence of lateral cephalometric radiography in orthodontic diagnosis and treatment planning. Angle Orthod. 2015;85(2):206-10.
15. Dhamnetiya D, Goel MK, Jha RP, Shalini S, Bhattacharyya K. How to perform discriminant analysis in medical research? explained with illustrations. J Lab Physicians. 2022;14(4):511-20.
16. Gong A, Li J, Wang Z, Li Y, Hu F, Li Q, et al. Cranial base characteristics in anteroposterior malocclusions: a meta-analysis. Angle Orthod. 2016;86(4):668-80.
17. Polat OO, Kaya B. Changes in cranial base morphology in different malocclusions. Orthod Craniofac Res. 2007;10(4):216-21.
18. Jacobson A. The "Wits" appraisal of jaw disharmony. Am J Orthod. 1975;67(2):125-38.
19. Chaiworawitkul M. Cephalometric norms of northern Thais. J Thai Assoc Orthod. 2008;7:1–7.
20. Tseng YC, Pan CY, Chou ST, Liao CY, Lai ST, Chen CM, et al. Treatment of adult class III malocclusions with orthodontic therapy or orthognathic surgery: receiver operating characteristic analysis. Am J Orthod Dentofacial Orthop. 2011;139(5):e485-93.
21. Lersinghanart K, Boonpratham S, Luppanapornlarp S. Correlation between H angles and visual perception in skeletal type I females. M Dent J. 2020;40(3):257-66.
22. Sutthiprapaporn P, Manosudprasit A, Pisek A, Manosudprasit M, Pisek P, Phaoseree N, et al. Establishing esthetic lateral cephalometric values for Thai adults after orthodontic treatment. Khon Kaen Dent J. 2020;23(2):31-41.
23. Burns NR, Musich DR, Martin C, Razmus T, Gunel E, Ngan P. Class III camouflage treatment: what are the limits?. Am J Orthod Dentofacial Orthop. 2010;137(1):9-e1.
24. Benyahia H, Azaroual MF, Garcia C, Hamou E, Abouqal R, Zaoui F. Treatment of skeletal class III malocclusions: orthognathic surgery or orthodontic camouflage? how to decide. Int Orthod. 2011;9(2):196-209.
25. Chu YM, Bergeron L, Chen YR. Bimaxillary protrusion: an overview of the surgical-orthodontic treatment. Semin Plast Surg. 2009;23(1):32-9.
26. Kim YJ, Lee BK. Recent trends in orthognathic surgery in Asia. Facial Plast Surg Clin North Am. 2021;29(4): 549-66.
27. Blagitz MN, Almeida GA, Normando D. Factors associated with the stability of compensatory orthodontic treatment of class III malocclusion in the permanent dentition. Am J Orthod Dentofacial Orthop. 2020;158(5):e63-e72.
28. Lisboa CO, Borges MS, Medeiros PJD, Motta AT, Mucha JN. Orthodontic-surgical retreatment of facial asymmetry with occlusal cant and severe root resorption: a 3-year follow-up. Am J Orthod Dentofacial Orthop. 2017;152(2):268-80.