Title Page

Article Title:
Diagnosis and Conservative Treatment of Skeletal Class III Malocclusion with Anterior
Crossbite and Asymmetric Maxillary Crowding

Author names and affiliations:
a. Tseng, Linda LY
Lecturer,
Beethoven Orthodontic Center,No. 6, Ln.59, Jiangong 1st Rd., East Dist., HsinChu
city 300, Taiwan
E-mail: pgshmom@hotmail.com!
b. Chang, Chris CH
Director,
Beethoven Orthodontic Center,No. 6, Ln.59, Jiangong 1st Rd., East Dist., HsinChu
city 300, Taiwan
E-mail: beethoven.tw@gmail.com, beeth.oven@hinet.net!
c. Roberts, W. Eugene
Affiliations:
• Professor Emeritus of Orthodontics, Indiana University, School of Dentistry, 1121 W.
Michigan St. Indianapolis, IN 46202
• Adjunct Professor of Mechanical Engineering, IUPUI, Indianapolis. IN 46202
• Visiting Professor of Orthodontics, Loma Linda University, School of Dentistry, Loma

 Linda, CA 92350
E-mail: werobert@iu.edu

Corresponding author:
Roberts, W. Eugene
Affiliations:
• Professor Emeritus of Orthodontics, Indiana University, School of
Dentistry, 1121 W. Michigan St. Indianapolis, IN 46202
_________________________________________________________________________________
This is the author's manuscript of the article published in final edited form as:
Tseng, L. L. Y., Chang, C. H., & Roberts, W. E. (2016). Diagnosis and conservative treatment of skeletal Class III
malocclusion with anterior crossbite and asymmetric maxillary crowding. American Journal of Orthodontics and
Dentofacial Orthopedics, 149(4), 555–566. http://doi.org/10.1016/j.ajodo.2015.04.042

• Adjunct Professor of Mechanical Engineering, IUPUI, Indianapolis. IN
46202
• Visiting Professor of Orthodontics, Loma Linda University, School of
Dentistry, Loma 
 Linda, CA 92350
Phone: 317-823-6115 or 317-410-2805
Address: 8260 Skipjack Drive, Indianapolis, IN 46236
E-mail: werobert@iu.edu, werobert@me.com

*Highlights (for review)

Highlights:
1. Without extractions or orthognathic surgery, a differential diagnosis,
utilizing three methods (DI, 3-Ring and Extraction Decision Tree)
revealed that the patient’s desire for conservative treatment was feasible.
2. Despite 12mm of asymmetric crowding in the maxillary arch, the problem
was treated to an optimal result without excessive arch expansion and
incisal flaring by using PSL brackets.
3. For the present patient, the anterior cross bite and deep bite were
corrected simultaneously in ~5 months, utilizing anterior BTs and early
light class III elastics as the principle active mechanics.

*Manuscript (no author identifiers please)
Click here to view linked References

Diagnosis and Conservative Treatment of Skeletal Class III Malocclusion with Anterior Crossbite and
Asymmetric Maxillary Crowding
Abstract
A 28-year-9-month male presented for orthodontic consultation for skeletal Class III malocclusion (ANB
-30) with a modest asymmetric Class II/III molar relationship, complicated by an anterior crossbite, deep
bite, and 12mm of asymmetric maxillary crowding. Despite the severity of a malocclusion, Discrepancy
Index (DI) = 37, the patient desired non-invasive camouflage treatment. Lin’s 3-Ring diagnosis revealed
that treatment without extractions or orthognathic surgery was a viable approach. Arch length analysis
indicated that differential interproximal enamel reduction (IPR) could resolve the crowding and midline
discrepancy, but a miniscrew in the infrazygomatic crest (IZC) was needed to retract the right buccal
segment. The patient accepted the complex, staged treatment plan with the understanding that it would
require ~3.5 years. Fixed appliance treatment with passive self ligating (PSL) brackets, early light short
elastics (ELSE), bite turbos (BTs), IPR, and IZC retraction opened the vertical dimension of occlusion
(VDO), improved the ANB 20 and achieved an excellent alignment, as evidenced by a CRE of 26 and a
Pink and White (P&W) dental esthetic score of 3. The worksheets for the DI, CRE, and P&W scores are
attached within this case report.
Key words: Skeletal Class III, anterior crossbite, deep-bite, 3-ring diagnosis, bite turbos (BTs),
interproximal enamel reduction (IPR), early light short elastics (ELSE)
Introduction
Angle’s1 classification for malocclusion focused on the occlusal relationship of the first molars, so it can
be misleading for many malocclusions. Likewise anterior crossbites may be deceptive, particularly when
associated with a prognathic skeletal pattern and concave face. An unusual case is presented that
appears to be a modest problem based on the molar discrepancy, but it is a severe malocclusion, based
on an American Board of Orthodontics (ABO) Discrepancy Index (DI) score of 37. Furthermore, the
face, anterior crossbite, and the ANB angle of -30 are consistent with a skeletal Class III malocclusion.
Despite the severity of the problem, the patient insisted on the most conservative treatment possible,
so a careful differential diagnosis was critical to determine if a relatively noninvasive approach was
indicated or even possible.
Anterior crossbites with a Class III skeletal pattern present a layer of complexity that is not readily
diagnosed unless a systematic test is used such as Lin’s 3-Ring diagnosis method.2, 3 A careful
application of the DI and 3-Ring methods demonstrated that conservative treatment was feasible.
1

However, optimal sagittal alignment of the dentition required a stainless steel miniscrew
(OrthoBoneScrew® (OBS) Newton’s A, Hsinchu, Taiwan) in the right infrazygomatic crest (IZC) to
retract the right buccal segment.
Diagnosis and Etiology
A 28-year-9-month-old male presented for orthodontic consultation with the following chief concerns:
thin upper lip, irregular dentition and poor smile esthetics. Figure 1 There was no contributing medical or
dental history. Clinical examination revealed a retrusive upper lip, deep anterior cross-bite of all
maxillary incisors, and posterior lingual crossbite of the maxillary right second premolar and irregular
dental attrition of the maxillary right central incisor. Figure 1 The overbite was 7mm and overjet was -3
mm. There was present 12mm of asymmetric crowding in the upper arch; Asymmetric Class II (right);
and Class III (left) buccal segments associated with a midline deviation of the maxilla that was 3mm to
the right. Figure 2 Radiographic and cephalometric survey before treatment is provided respectively. Figure
3

The cephalometric measurements are summarized in the following. Table 1 Superimposed cephalometric

tracings before and after treatment document the skeletal and dental changes. Figure 7 The severely worn
facet on the maxillary right central incisor (#8) required coordinated orthodontic alignment and
restorative care. Figure 8
Specific Objectives of Treatment
Maxilla (all three planes):
• A - P: Maintain
• Vertical: Maintain
• Transverse: Maintain
Mandible (all three planes):
• A - P: Maintain
• Vertical: Clockwise rotation to improve the ANB angle
• Transverse: Maintain
Maxillary Dentition
• A - P: Protract incisors and retract the molars
• Vertical: Slightly increase
• Inter-molar Width: Slightly increase
Mandibular Dentition
• A - P: Retract
2

• Vertical: Intrude incisors
• Inter-molar / Inter-canine width: Maintain
Facial Esthetics
• Increase the upper lip protrusion
• Increase the vertical dimension of occlusion (VDO) to achieve an orthognathic profile
Treatment Alternatives
After a careful evaluation of the patient’s problems, three tentative treatment plans were proposed.
Treatment plan A was extraction of the upper second premolars and the lower first premolars.
Treatment plan B was insertion for two miniscrews in the buccal shelf of the mandible to retract the
entire lower arch. Treatment plan C was non-extraction camouflage treatment, using Class III elastics
to retract the lower labial segment and protract the upper labial segment. The patient chose the most
conservative option, treatment plan C. However, this relatively noninvasive approach required
extensive IPR of the anterior maxillary arch, and an OBS in the IZC to retract the right buccal segment.
The patient was informed that this conservative approach would require 3-4 years of treatment,
primarily because of the sequence of procedures necessary to resolve 12mm of asymmetric crowding in
the maxillary arch, without extracting teeth. The patient accepted this treatment limitation.
1. No extractions or orthognathic surgery
2. Damon Q® brackets (Ormco, Glendora, CA): standard torque PSL brackets bonded upside down
on teeth #6-11 to resist the flaring effect of Class III elastics
3. Open coil springs between teeth #3-5 and #6-8 for opening space to relieve crowding
4. BTs on #22 and 27 initially, and then on #24 and 25 as the bite opens
5. Class III ELSE to assist with anterior cross-bite correction and open the VDO
6. OBS in the right IZC to retract the right buccal segment
7. Restore tooth #8 with a porcelain veneer or composite resin
Appliances and Treatment Progress
The 0.022” slot Damon Q standard torque brackets were bonded on the lower arch. Bite turbos were
bonded on the lingual surface of teeth #22 and 27, to open the bite and facilitate anterior crossbite
correction. Figure 9a, b, c. One month later the upper arch was bonded with standard torque brackets, but
those on teeth #6-11 were bonded upside down to deliver negative torque. Table 2 Initially, there was
inadequate space to bond teeth #4 and 7, so open coil springs were placed on the archwire, and those
3

teeth were bonded with upside down, standard torque brackets as soon as adequate space was available.
The length of the active NiTi springs for space opening was 1-1.5X bracket-widths longer than the
space needed. Tooth #8 was severely worn with dentine exposure. The amount of lost tooth structure
was estimated to be ~2mm in the axial dimension, so the bracket position for tooth #9 was 6mm from
the incisor edge, while the corresponding distance for tooth #8 was only 4mm Figure 10. The goal was to
achieve optimal gingival alignment and then restore the #8 tooth structure as needed. The initial
arch-wires were 0.014” CuNiTi. Class III ELSE (Quail 3/16” 2 oz) (Ormco, Glendora, CA) were
placed from teeth #21 to 14 and #28 to 3. Figure 11,12 BTs were bonded on the lingual surface of #24 and
25. Figure 13 The stepwise opening of the bite with BTs was for patient comfort. The patient was
instructed to wear 2oz ELSE full time, and to replace them with new ones at least four times per day,
preferably after meals or snacks. By the 5th month of treatment, the anterior crossbite was corrected, the
BTs were removed, and the lower arch wire was changed to 0.014x0.025” CuNiTi. In the 7th month, the
upper arch wire was changed to 0.014x0.025” CuNiTi. Drop-in hooks (Ormco, Glendora, CA) were
fitted into the vertical slot of the maxillary canines to secure class II elastics (Fox 1/4” 3.5 oz), which
accomplished A-P correction while promoting development of the smile arc. The change from Class
III to Class II elastics at 7 months was necessary due to the opening of the bite and 20 improvement in
the ANB angle. Figure 14
In the 8th month, the open coil springs were reactivated with a light-cured resin ball or a crimpable stop.
Figures 15-17

In the 10th month, the lower anteriors were too lingually inclined, so the archwire was changed

to a 0.016x0.025” NiTi, pre-torqued with 20° of lingual root torque. In the 15th month of active
treatment, the upper archwire was replaced by 0.017x0.025” TMA. By 18 months, there was still
inadequate space to align tooth #4 and additional coil spring activation was contraindicated. In the 21st
month, OBSs were inserted at the right IZC, and an elastomeric chain was attached to retract the upper
right canine. Figures 18 and 19 Three months later (24 months of treatment), no significant space opening to
align tooth #4 had been achieved. In the 25th month of the treatment, IPR was performed from #7-10
and along the mesial aspect of #3. Figures 20, 21, and 22 Then teeth #6-10 were tied together with a power
tube. In the 27th month, space opened on the mesial side of #4.

In the 28th month, a button was

bonded on tooth #4 and an elastomeric chain was used for buccal traction to align it. Figure 23 In the 32nd
month, #4 was engaged on a 0.014” NiTi archwire. Figure 24 At 38 months of treatment, tooth #4 was
finally aligned. Figure 25 Two weeks prior to the completion of active treatment, the upper archwire was
sectioned distal to cuspids, and box elastics (Fox 1/4” 3.5 oz) were used to improve occlusal contacts.
After 42 months (3.5 years as projected) of active treatment, all appliances were removed and two
retainers were delivered: upper clear overlay and a maxillary anterior 2-2 fixed.

4

Results Achieved
Maxilla (all three planes):
• A - P: Maintained
• Vertical: Maintained
• Transverse: Maintained
Mandible (all three planes):
• A - P: Maintained
• Vertical: Clockwise rotation to increase the VDO and ANB
• Transverse: Maintained
Maxillary Dentition
• A - P: Flared incisors (102 to 114.5°)
• Vertical: molars retracted and extruded
• Inter-molar / Inter-canine Width: Maintained
Mandibular Dentition
• A - P: Maintained
• Vertical: Incisors were intruded, molars were extruded.
• Inter-molar / Inter-canine Width: Maintained
Facial Esthetics:
• Produced a facial profile with normal convexity
Retention
A fixed retainer was bonded on all maxillary incisors. A clear overlay retainer was delivered for the
upper arch and the patient was instructed to wear it full time for the first 6 months and nights only
thereafter. Instructions were provided for oral hygiene and maintenance of the retainers.
Final Evaluation of Treatment
Both arches were well aligned and optimally inter-digitated in a near ideal Class I occlusion, with
coincident dental. Figure 5 The facial profile was improved primarily by increasing the relative prominence
of the upper lip and increasing the VDO. Figure 4 Comparing the pre-treatment and post-treatment
cephalometric tracings reveals that SN to mandibular plane angle increased 1° due to the clockwise
rotation of the mandible. Figure 6 The axial inclination of the upper incisors to SN increased from 102 to
114.5°. Table 1 The lower incisors were intruded, but all of the molars were extruded. Figure 7 The CRE CRE
5

score was 26 points as shown in the subsequent work sheet. Most of the points deducted were for a
lack of occlusal contacts (6 points). Dental esthetics was excellent as documented by the P&W dental
esthetic index of 3, as scored in the form at the end of this report. P&W Although the conservative
treatment plan required 3.5 years of active treatment, the patient was very pleased with the results.

Discussion
Conservative treatment of a class III skeletal malocclusion is popular with patients but is challenging
for orthodontists. There were four principal factors contributing to the successful conservative
management: 1. accurate diagnosis, 2. advanced fixed appliances, 3. custom auxiliaries, and 4.
interproximal enamel reduction.2, 3 After determining the complexity of a malocclusion with the DI, DI a
realistic diagnosis and treatment plan are facilitated by two stepwise differential tests: 3 Ring Diagnosis
System Figure 26 and the Extraction Decision-Making Tree. Table 3
Skeletal Class III malocclusion is often confused with pseudo Class III problems4 which typically have
a functional shift (FS) and/or anterior crossbite with Class I buccal segments. Lin5 reported that the
prevalence of skeletal class III malocclusion is about 1.65% in Taiwan, but pseudo class III problems
(Class I with anterior crossbite) are found in approximately 2.31% of children 9-15 years of age. The
Three-Ring Diagnosis method Figure 26 was developed to help predict the prognosis for anterior
cross-bite correction.6 The clinical data revealed that 90% of anterior cross bite corrections were stable
if the following diagnostic criteria were met:
• Profile: an acceptable facial profile in centric relation (CR)
• Class: canines and molars in or near a Class I relationship
• FS: a functional shift is evident
Good candidates for conservative (camouflage) treatment have an orthognathic profile (acceptable
facial balance) in centric relation (CR), buccal segments that are approximately Class I, and a FS.7 There
were other favorable indicators such as a marginally low to average mandibular plane angle and no
open bite. Orthodontic camouflage to treat a class III malocclusion may result in increased axial
inclination of the maxillary incisors and decreased axial inclination of the mandibular incisors,
particularly if there is an underlying class III skeletal discrepancy.8 If it is necessary to retract the
mandibular incisors, an axial inclination of at least 880 is desirable.9
The Chang10 decision-making tree Table 3 was used to assess the necessity for extractions. The two factors
favoring extraction were protrusive profile and crowding >7mm in the upper arch. However, maxillary
extractions would complicate the correction of the anterior cross bite and may result in mid-face
6

deficiency. Furthermore, the patient was strongly opposed to extractions, so the non-extraction option
was selected, with the understanding that extensive IPR as well as IZC anchorage were necessary.
PSL brackets with light wires facilitate the conservative correction of Class III malocclusions.7 The
bracket is a tube-like appliance capable of delivering continuous light force that is similar to the MEAW
(Multiloop Edgewise Arch Wire) effect.7,11,12 If a patient meets the three criteria of the 3-Ring diagnosis,
straight wires and Class III elastics are usually sufficient to correct the malocclusion.2 For the present
patient, Class III ELSE were used initially with BTs, but were then replaced with Class II elastics as
soon as the bite opened and the anterior crossbite was corrected. These are common mechanics for
patients with an anterior crossbite and Class I buccal segments. If it is necessary to manage an
asymmetry and/or retract the entire lower arch, bilateral buccal shelf OBSs are indicated.7, 12, and 13
Proper torque control with PSL brackets and light NiTi wires can be challenging.14 For the present
patient, dental axial inclinations were managed with low torque brackets Table 2, pre-torqued arch-wires,
and TAD anchorage to retract the right buccal segment. Controlling torque with the selection of
brackets is particularly effective with PSL brackets1 5.16 Table 2. Low torque was used on the upper incisors
to compensate for the side-effects of the class III elastics, i. e. flaring of maxillary incisors and excessive
retraction of mandibular incisors.17 If low torque brackets are insufficient for controlling axial
inclinations, bonding standard torque brackets upside down is a viable alternative15-17 Table 2. If a
rectangular archwire fails to generate adequate root torque, a 20° pre-torqued archwire such as
0.016x0.025” or 0.019x0.025” is recommended. Since the present patient had standard torque brackets
bonded on the mandibular teeth, a 0.016x0.025” Ni-Ti archwire with 20° of torque was inserted 10
months into treatment to correct the axial inclinations in the anterior segment.17 This problem could
have been prevented by using higher torque brackets in the lower anterior segment initially Table 2.
Correction of deep bite can be achieved by molar extrusion, incisor intrusion or both. The current
patient’s deep bite was corrected with anterior BTs, which intruded the lower incisors and allowed the
posterior segments to extrude. Figure 7 An advantage for anterior BTs at the beginning of treatment was
to serve as vertical stops for the deep overbite, as well as to unlock the posterior interdigitation, to
allow the malocclusion greater freedom for three dimensional tooth movement. 15-17 BTs for class III
treatment have additional advantages: 1. protect the enamel from attrition, 2. prevent accidental bracket
debonding, 3. improve the effect of light wires for 3D tooth movement such as correction of posterior
crossbites, 4. improve the response to ELSE, and 5. help correct mandibular plane angle problems.15
For deep anterior crossbites, a stepwise opening of the bite with BTs is more comfortable for the
patient. Figure 9a-c, 12, and 13

7

For the present patient, the anterior cross bite and deep bite were corrected simultaneously in ~5
months, utilizing class III elastics as the principle active mechanics.15-17 Starting 2 oz ELSE during the
leveling phase enhanced the treatment efficiency by helping to level the arches and achieve correction
in the sagittal plane.14,15 The side-effects of the class III elastics are labial tipping of upper incisors,
extrusion of maxillary molars, and distal tipping of lower molars.15-17 Since these effects were considered
favorable for the present patient, class III elastics were used rather than inserting bone screws in the
buccal shelf of the mandible.12
At 21 months a OBS was placed at the right IZC to provide anchorage to retract the canine, avoid
incisor flaring, and retract the molars. However, these mechanics failed to open adequate space for
alignment of #4. Figures 18 and 19 So IPR was performed with an air rotor and abrasive finishing strips in the
anterior segment of the upper arch to reduce black triangles, gain space for alignment of #4, improve
tooth proportion, and establish more ideal interproximal contacts. 18-19. Figures 20, 21, and 22
The pink and white (P&W) esthetic score evaluates anterior maxillary esthetics by analyzing clinical
photographs. Refer to the scoring form at the end of this case report. The form includes two esthetic
assessments: 1. Pink is a gingival evaluation, and 2. White is a score of dental micro-esthetics. The
column on the right lists six variables that are scored from 0-2 for each assessment. The actual P&W
score is marked with red circles for the six variables in the areas highlighted in blue.21 The deficiencies
scored were blunted mesial and distal gingiva papillae, creating small dark triangles between the incisors,
inadequate incisal curve (smile line), and apparent deviation from ideal incisal root angulation. Three
points or less on the P&W score is considered an excellent result, particularly for patients with incisal
abrasion.
The anterior cranial base superimposition Figure 7 shows that the mandible rotated posteriorly about
4mm but the FMA only opened 1 degree, because the posterior mandible moved inferiorly. This
unusual pattern of mandibular rotation may indicate a morphologic problem in the TMJ(s). In
retrospect, it may have been wise to utilize a CBCT prospectively to evaluate the joints. Furthermore, a
CBCT may be a wise precaution for assessing all skeletal malocclusions that require surgery and/or
temporary anchorage devices.

Conclusion

8

This difficult skeletal malocclusion (ANB -30, DI = 37) was treated to an excellent result (CRE = 26)
without extractions or orthognathic surgery. A differential diagnosis, utilizing three methods (DI,
3-Ring and Extraction Decision Tree) revealed that the patient’s desire for conservative treatment was
feasible. A carefully sequenced treatment plan achieved an excellent result for this severe malocclusion,
but it did require 3.5 years of treatment. In retrospect, the treatment time may have been decreased by
introducing IPR and IZC anchorage earlier in the sequence, but the necessity for those more invasive
measures was not clear until ~18 months into treatment. Despite 12mm of asymmetric crowding in the
maxillary arch, the problem was treated to an optimal result without excessive arch expansion and
incisal flaring.20
Acknowledgment
Thanks to Teacher Paul Head for proofreading this article.
References
1. Angle EH. Classification of malocclusion. Dent Cosmos 1899;41(3):248-64
2. Lin JJ. The most effective and simplest ways for treating severe Class III without extraction or
surgery. IJOI 2014;33:4-18
3. Yeh HY, Lin JJ, Roberts WE. Conservative adult treatment for severe class III openbite
malocclusion with bimaxillary crowding. IJOI 2014;34:12-25
4. Kelly J, Harvey C. An assessment of the teeth of youths 12-17 years. Washington DC: National
Center for Health Statistics, US Public Health Service; 1977. Publication No. (HRA) 74-1644
5. Lin JJ. Prevalence of malocclusion in Taiwan children age 9-15. Clin Dent 1984;4:227-34
6. Lin JJ. Creative Orthodontics Blending the Damon System & TADs to Manage Difficult
Malocclusion 2ed. Taipei: Yong Chie; 2010 p 263-271
7. Lin JJ, Liaw JL, Chang HN and Roberts WE. Class III Correction Orthodontics. 2013. Yong Chieh
Enterprise Co, Ltd., Taiwan. Published electronically on Apple iBooks as Orthodontics Vol. 3: Class III
Correction.
8. Costa-Pinho T, Torrent J, Pinho J. Orthodontics camouflage in the case of a skeletal class III
malocclusion. World Orthod 2004;5:213-23
9. Bennett J, McLaughlin RP, Trevisi HJ. Systemized orthodontics treatment mechanics. Mosby Inc.
London. 2001
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10. Chang CH. Advanced Damon Course No.1: Extraction Decision-Making Tree. Beethoven Podcast
Encyclopedia in Orthodontics 2011, Newton’s A Ltd, Taiwan
11. Pollard AP. Capturing the essence of the Damon approach. Clin Impression 2003;12:4-11
12. Lin JJ. Treatment of severe Class III with buccal shelf mini-screws. News & Trends in Orthodontics
2010;18:3-12
13. Huang S. Non-extraction management of skeletal class III malocclusion with facial asymmetry.
News & Trends in Orthodontics 2010;20:22-31
14. Kozlowski J. Honing Damon system mechanics for the ultimate in efficiency and excellence. Clin
Impressions 2008;16:23-28
15. Pitts T. Begin with the end in mind: bracket placement and early elastics protocols for smile arc
protection. Clin Impressions 2009;17:4-13.
16. Huang S., Pitts T., secrets of excellent finishing. News & Trends in Orthodontics 2009;14:6-23
17. Chang CH. Basic Damon Course No. 5: Finish Bending, Podcast Encyclopedia in Orthodontics
2012, Newton’s A Ltd, Taiwan.
18. Zachrisson BU, Nyoygaard L, Mobarak K. Dental health assessed more than 10 years after
interproximal enamel reduction of mandibular anterior teeth. Am J Ortho Dentofacial Orthop
2007;131:162-169.
19. Hsu YL. Approaching efficient finishing with hard and soft tissue contouring, Part II: hard tissue
contouring. News & Trends in Orthodontics 2008;11:17-19
20. Liaw JL. Molar retraction in all four quadrants to correct a Class III, crowded malocclusion in a
patient with a flat profile. Int J of Ortho Implantol 2012;27:20-31.
21. Su B. IBOI Pink and White esthetic score. Int J of Ortho Implantol 2012;28:80-85.

10

Figure Legends:
Figure 1.

Pretreatment facial and intraoral photographs

Figure 2.

Pretreatment study models (casts).

Figure 3.

Pretreatment panoramic radiograph, lateral cephalometric radiograph and cephalometric

tracing, showing a protruded lower lip and crowding of upper arch.
Figure 4.

Posttreatment facial and intraoral photographs

Figure 5.

Posttreatment study models (casts).

Figure 6.

Posttreatment panoramic radiograph, lateral cephalometric radiograph and cephalometric

tracing, showing improved profile and the parallel alignment of all tooth roots.
Figure 7.

Initial (black) and finish (red) cephalometric tracings are superimposed on the anterior

cranial base (left), as well as on the stable skeletal structures of the maxilla (upper right), and mandible
(lower right).
Figure 8.

A severely worn facet along the incisal surface of tooth #8 had dentinal exposure.

Figures 9a, 9b, and 9c. Bite turbos on the lingual side of #22 and 27 were used to disarticulate the
occlusion (open the bite). Bite turbos for lower incisors are made with a Mini-Mold (Ortho-Arch,
Schaumburg, IL) for a 5mm bite ramp bonder (upper). The mold (bonder) is filled with composite
resin, positioned against the lingual surface of the tooth, and then cured with light (lower).
Figure 10.

Two open coil springs were inserted to create space for teeth #4 and 7. Standard torque

brackets were bonded upside down on teeth #6, 8, 9, 10, and 11. The bracket position for teeth #8 and
9 were at the same level relative to the gingival margin.
Figure 11.

Class III ELSE from teeth #3-28 (Quail 3/16” 2 OZ.)

Figure 12. Class III ELSE are applied between teeth #14 and 21. Note that tooth #9 bites on bite
turbo.
Figure 13.

Bite turbos are bonded at the lingual surface of lower anteriors to prevent bracket

interference while correcting the cross bite. They also assisted with intrusion of teeth #22-27.
Figure 14. In the 5th month of treatment, the anterior cross-bite was corrected so the anterior bite
11

turbos were removed. At the same appointment, the lower arch wire was changed to 0.014x0.025”
CuNiTi.
Figure 15.

The open coil spring was reactivated by adding a light-cured resin ball.

Figure 16.

The open coil spring is reactivated by installing a crimpable stop mesial to the maxillary

first molar.
Figure 17. At 18 months of treatment there was still inadequate space to align tooth #4.
Figures 18 and 19. At 21 months, an OrthoBoneScrew (OBS) (Newton’s A, Hsinchu, Taiwan) was
placed in the right infrazygomatic crest (IZC) and a power chain was attached from tooth #6 to the
OBS to retract the right buccal segment as the space was opened for tooth #4. At 24 months, no space
was gained to align tooth #4.
Figures 20, 21, and 22. At 25 months, IPR was performed on the mesial surface of tooth #3 (left)
and inter-proximally from teeth #7-10 (center). All adjusted surfaces were polished with abrasive strips
(right).

A coil spring was placed at 25 months (upper left) to open space for tooth #4 by pushing the

premolar and canine mesially to close the anterior space that was created by IPR.
Figure 23. After 30 months a button was bonded on the buccal surface of tooth #4 and an elastic chain
was attached. It was activated by attaching the opposite end to the IZC miniscrew.
Figure 24. At 36 months a bracket was bonded on the buccal surface of tooth #4 and it was engaged
on an 0.014” CuNiTi archwire.
Figure 25. At 38 months tooth #4 was aligned and a 0.017x0.025” TMA archwire was engaged.
Figure 26. The class III diagnosis system developed by Dr. Lin has simplified the complicated
diagnostic procedure for assessing anterior crossbite.6
Table 1. Cephalometric summary
Table 2. DamonQ (DQ) Torque brackets are available in high, standard and low torque for both arches,
as indicated. For the upper arch (U1, U2, and U3) the bracket can be placed upside down to deliver
super low torque, as indicated.
Table 3. The Chang10 decision-making tree summarizes aids used to decide on an extraction vs.
non-extraction treatment plan.
12

Worksheet 1. The American Board of Orthodontics (ABO) Discrepancy Index (DI)
Worksheet 2. The American Board of Orthodontics (ABO) Cast-Radiograph Evaluation (CRE)
Worksheet 3. Pink and White esthetic score

13

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Table

CEPHALOMETRIC
SKELETAL ANALYSIS
PRE-TX

POST-TX

DIFF.

SNA°

81°

81°

0°

SNB°

84°

82°

2°

ANB°

-3°

-1°

2°

SN-MP°

28°

29°

1°

FMA°

23°

24°

1°

DENTAL ANALYSIS
U1 TO NA mm

3 mm

7 mm

4 mm

U1 TO SN°

102°

114.5°

12.5°

L1 TO NB mm

3 mm

3 mm

0 mm

L1 TO MP°

88°

91.5°

3.5°

FACIAL ANALYSIS
E-LINE UL

-5 mm

-4 mm

1 mm

E-LINE LL

-0.5 mm

-2 mm

1.5 mm

1

Table

DQ Torque
Torque

U1

U2

U3

High

22

13

11

Std

15

6

7

Low

2

-5

-9

Std upside down

-15

-6

-7

Torque

L1

L2

L3

High

11

11

13

Std

-3

-3

7

Low

-11

-11

0

1

Table

Ext.

Not

Protrusion

Straight

2. Md. angle

High

Low

3. Bite

Open

Deep

4. Ant. inclination

Flaring

Flat

5. Crowding

> 7mm

None

6. Decay/missing

Present

????

7. P’t perception

OK

No

1. Profile

8. Etc…

1

IBOI Cast-Radiograph Evaluation

Occlusal Contacts

Table

Case #

Patient

IAOI CASE REPORT

Total Score:

Occlusal Contacts

Cast-Radiograph Evaluation

8

Alignment/Rotations
Case #

1

Patient

Total Score:

28

Alignment/Rotations
1
1

3

1

1

1

1

1

1

1
1

1

Marginal Ridges
Occlusal Relationships
Marginal Ridges
Occlusal Relationships

3
11

4
1

1

1

1
Buccolingual Inclination

1
2

1
Interproximal
Contacts1
Interproximal Contacts

Buccolingual Inclination

0
5

1

1

2

1

Overjet

Root Angulation

Overjet
4

1

1

1
1

1

1

1

1

INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white Place
box. Mark
extracted
teeth deficient
with “X”. tooth
Second
molars
should
in occlusion.
INSTRUCTIONS:
score
beside each
and
enter
total be
score
for each parameter

in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.

Table

P(Rev.
ATIENT
  CHAO-YUEN CHIU 
CASE #
1
9/22/08)
TOTAL D.I. SCORE
25

IAOI CASE REPORT
OVERJET

0 mm. (edge-to-edge)

=

1 pt.

3.1 – 5 mm.
=
2WORKSHEET
pts.
DISCREPANCY
INDEX

5.1 – 7 mm.
=
3 pts.
P(Rev.
ATIENT
  CHAO-YUEN CHIU 
C7.1
ASE
– 9# mm. 1
= 9/22/08) 4 pts.
T>OTAL
25 5 pts.
9 mm.D.I. SCORE
= 37

Negative OJ (x-bite) 1 pt. per mm. per tooth =
OVERJET
0 mm. (edge-to-edge) =
1 pt.
1 – 3 mm.Total
==
0 pts. 5
3.1 – 5 mm.
=
2 pts.
OVERBITE
5.1
– 7 mm.
=
3 pts.
7.1 – 9 mm.
=
4 pts.
3 mm.
pts.
>09–mm.
==
5 0pts.
3.1 – 5 mm.
=
2 pts.
5.1 – 7 mm.
= mm. per
3 pts.
Negative
OJ (x-bite) 1 pt. per
tooth =
Impinging (100%)
=
5 pts.

2+ 2+ 2+ 3+ 2+ 2
=
5
13
=
5

OVERBITE
0ANTERIOR
– 3 mm.
=
0 pts.
OPEN BITE
3.1 – 5 mm.
=
2 pts.
5.1
– 7 mm.
pts.
0 mm.
(edge-to-edge), 1= pt. per3tooth
Impinging
(100%)
=
5
then 1 pt. per additional full mm.pts.
per tooth
Total
Total

==

35 0

=
=

1 pt.
2 pts.
4 pts.
7 pts.

01

CROWDING (only one arch)
1OCCLUSION
– 3 mm.
=
1 pt.
3.1
–
5
mm.
=
2 0pts.
Class I to end on
=
pts.
5.1
– 7onmm.
4 2pts.
End
Class II or III = =
pts. per side       pts.
>Full
7 mm.
==
7 4pts.
Class II or III
pts. per side       pts.
Beyond Class II or III =
1 pt. per mm.       pts.
Total
=
1 additional

7

Total
OCCLUSION

=

Total

EXAM YEAR
2009
    
BUCCAL
POSTERIOR
ABO ID#
96112 X-BITE
2 pts. per tooth

Total

=
=
=
=

Total

=

0

1 x 1 pt. =      
1
BUCCAL
POSTERIOR
X-BITE
Each degree
< -2°      
2 pts.
perdegree
tooth > 6°      
Total = x 1 pt. = 2     
Each
0

SN-MP
CEPHALOMETRICS
≥ 38°
ANB
≥ degree
6° or ≤> -2°
Each
38°

(See Instructions)

= 2 pts.
=
x 2 pts. = 4 pts.

Each degree < -2°      
≤ 26°

x 1 pt. =      
= 1 pt.

Eachdegree
degree> <6°26°
1 pt.
Each
      4 x 1xpt.
= =     4
1 to MP ≥ 99°
SN-MP
≥ 38°
Each
degree > 99°
Each degree > 38°

=

1 pt.
2
x 1 pt.= = 2 pts.2
x 2 pts. =
= = 1 pt. 85
Total
4
x 1 pt. =
4

1 to
MP ≥ 99° teeth
Supernumerary

1 pt.
      =x 1 pt.
=      
     
Ankylosis
of
perm.
teeth
x
2
pts.
Each degree > 99°
2
x 1 pt. =
2 =      
      x 2 pts. =      
Anomalous morphology
Impaction (except 3rd molars)
x 2 pts. =
0
Midline discrepancy (≥3mm)
Total
=@ 2 pts.8 =      2
rd
Missing teeth (except 3 molars)       x 1 pts. =
      x 2 pts. =      
Missing teeth, congenital
OTHER
(See Instructions)
2
Spacing (4 or
more, per arch)
      x 2 pts. =
2
Spacing
(Mx cent. diastema ≥ 2mm)
@ 2 pts.     
=
Supernumerary teeth
      x 1 pt. =
     
Tooth
transposition
     
x
2
pts.
=
      x 2 pts. =      
Ankylosis of perm. teeth
Skeletal asymmetry
(nonsurgical tx)
3 pts.
=
      x 2@pts.
Anomalous
morphology
=      
Addl.
treatment
complexities
     
x
2
pts.
=
1
2
rd
Impaction (except 3 molars)
x 2 pts. =      
Midline discrepancy (≥3mm)
Identify: ectopic eruption of
Missing teeth (except 3rd molars)      
     
Missing teeth, congenital
Spacing (4 or more, per arch)
     
Total
Spacing
(Mx
cent.
diastema
≥
2mm)
IMPLANT SITE
Tooth transposition
     

additional

@ 2 pts. =      

#4
x 1 pts. =

x 2 pts. =      
x 2 pts.
= = 44 2
2
@ 2 pts. =
x 2 pts. =      
Lip line
: Low (0 pt),
= =
Medium (1 pt), High (2 pts)
Skeletal
asymmetry
(nonsurgical
tx)
@ 3 pts.
Gingival
biotype
:
Low-scalloped,
thick
(0
pt),
Medium-scalloped,
Addl. treatment complexities       x 2 pts. =      medium-thick (1 pt),
High-scalloped, thin (2 pts)

0 pts.
4
2 pts. per side       pts.
4 pts. per side       pts.
1 pt. per mm.       pts.
04

20

=

LINGUAL POSTERIOR X-BITE
CEPHALOMETRICS
(See Instructions)
0
1 pt. per tooth
Total =
ANB ≥ 6° or ≤ -2°
0 = 4 pts.

Shape of tooth crowns :
Identify:

Class I to end on
End on Class II or III
Full Class II or III
Beyond Class II or III

01

=

Each degree < 26°
OTHER
(See Instructions)

then 1 pt. per additional full mm. per tooth
Total
=
0
Total
=
00
CROWDING (only one arch)

1 – 3 mm. OPEN BITE =
LATERAL
3.1 – 5 mm.
=
25.1
pts.–per
mm. per tooth =
7 mm.
> 7 mm.
=

1 pt. per tooth

≤ 26°

LATERAL OPEN
ANTERIOR
OPEN BITE
BITE
pts. (edge-to-edge),
per mm. per tooth
02mm.
1 pt. per tooth

Total
Total

96112

LINGUAL POSTERIOR X-BITE

1 – 3 mm.
=
0 pts.
Discrepancy
Index
Worksheet

Total
Total

ABO ID#

=

Rectangular (0 pt), Triangular (2 pts)

Bone level at adjacent teeth :
contact point (1 pt),

=

8

5 mm to contact point (0 pt), 5.5 to 6.5 mm to

7mm to contact point (2 pts)

Bone anatomy of alveolarTotal
crest :

=

=

4

H&V sufficient (0 pt), Deficient H, allow

simultaneous augment (1 pt), Deficient H, require prior grafting (2 pts), Deficient V or Both

=
Soft tissue anatomy :
H&V (3 pts)

Intact (0 pt), Defective ( 2 pts)

Infection at implant site :

=

None (0 pt), Chronic (1 pt), Acute( 2 pts)

0

=

Table
IAOI CASE REPORT

Pink & White Esthetic Score

3

Total Score: =

1. Pink Esthetic Score

Total =

6
5
2

3

4
1

1. M-D Papilla

0 1

2

2. Keratinized Gingiva

0 1

2

3. Curvature of Gingival Margin

0 1

2

4. Level of Gingival Margin

0 1

2

5. Root Convexity ( Torque )

0 1

2

6. Scar Formation

0 1

2

1. M&D Papilla

0 1

2

2. Keratinized Gingiva

0 1

2

3. Curvature of Gingival Margin

0 1

2

4. Level of Gingival Margin

0 1

2

5. Root Convexity ( Torque )

0 1

2

6. Scar Formation

0 1

2

2. White Esthetic Score ( for Micro-esthetics )

1

4

3

5
2

6

1

Total =

2

1. Midline

0 1

2

2. Incisor Curve

0 1

2

3. Axial Inclination(5°, 8°,10°)

0 1

2

4. Contact Area(50%,40%,30%)

0 1

2

5. Tooth Proportion(1:0.8)

0 1

2

6. Tooth to Tooth Proportion

0 1

2

1. Midline

0 1

2

2. Incisor Curve

0 1

2

3. Axial Inclination(5°, 8°,10°)

0 1

2

4. Contact Area(50%,40%,30%)

0 1

2

5. Tooth Proportion(1:0.8)

0 1

2

6. Tooth to Tooth Proportion

0 1

2

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