Research Article| Volume 28, ISSUE 3, P164-194, September 2022

TAD driven Class III camouflage: Eight point protocol to optimize efficiency, aesthetics and stability

Published:October 27, 2022DOI:
      Although Class III malocclusions are the least frequent, they are frequently harder to treat and more likely to need orthognathic surgery for the best treatment. The reported incidence of this malocclusion ranges from 1% to 18%, with Asian groups experiencing the greatest prevalence and Caucasian populations experiencing the lowest. Generally speaking, class III malocclusions can be divided into two groups: developing and non-developing. Early intervention utilizing two phases of therapy is frequently recommended for Class III malocclusions that are still developing, with children (ages 7 to 9) showing more orthopedic benefit. Several approaches have been suggested for treating adult Class III patients who are not developing, including multi-brackets with Class III elastics, extraction treatment, full arch distalization, and multi-loop edgewise therapy. These procedures aid in secure occlusions and appropriate interincisal relationships, but often require either intraoral or extraoral anchorage to retract the mandibular incisors. The patient's compliance is frequently crucial to the effectiveness of the treatment. This article will focus on identifying and comprehending the aspects that play a critical part in strategizing non-surgical treatment options for Class III malocclusions, as well as demonstrating the concepts utilizing an eight-point protocol to increase the efficacy, aesthetics, and stability.
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        • Venugopal A
        • Srirengalakshmi M
        • Marya A
        • Manzano P.
        Periodontally compromised severe skeletal Class III with open bite corrected by orthodontic camouflage using temporary anchorage devices.
        APOS Trends Orthod. 2020; 10: 253-258
        • 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 Jan; 137 (9.e1-9.e13; discussion 9-11PMID: 20122418)
        • Venugopal A
        • Nadela FM
        • Bowman SJ
        • Marya໿ A
        • Kochhar AS
        • Yadav R
        • Alam MK.
        Alternative treatment strategies for pseudo-Class III malocclusion with mild asymmetry.
        Kieferorthopädie. 2021; : 27-42
        • Zere E
        • Chaudhari PK
        • Sharan J
        • Dhingra K
        • Tiwari N.
        Developing Class III malocclusions: challenges and solutions.
        Clin Cosmet Investig Dent. 2018 Jun 22; 10 (PMID: 29950903; PMCID: PMC6016584): 99-116
        • Rabie AB
        • Gu Y.
        Diagnostic criteria for pseudo-Class III malocclusion.
        Am J Orthod Dentofacial Orthop. 2000 Jan; 117 (PMID: 10629513): 1-9
        • Nakasima A
        • Ichinose M
        • Nakata S
        • Takahama Y.
        Hereditary factors in the craniofacial morphology of Angle's Class II and Class III malocclusions.
        Am J Orthod. 1982; 82: 150-156
        • Akan B
        • Veli I.
        Comparison of dental arch and mandibular-maxillary base widths between true and pseudo-Class III malocclusions.
        Am J Orthod Dentofacial Orthop. 2017 Feb; 151 (PMID: 28153161): 317-323
        • Yadav R
        • Yadav AK
        • Birring L
        • Yadav N
        • Yadav PK
        • Alam MK
        • Marya A
        • Venugopal A
        Evaluation of dental arch width among angle's classification of malocclusion.
        Int Med J. 2021; 28: 558-561
        • Wang B
        • Fang B
        • Fan LF
        • Mao LX
        • Xia YH.
        [Measurement of alveolar bone thickness of adult skeletal Class III patients in mandibular anterior region].
        Shanghai Kou Qiang Yi Xue. 2012 Aug; 21 (Chinese. PMID: 23135118): 422-426
        • Lee S
        • Hwang S
        • Jang W
        • Choi YJ
        • Chung CJ
        • Kim KH.
        Assessment of lower incisor alveolar bone width using cone-beam computed tomography images in skeletal Class III adults of different vertical patterns.
        Korean J Orthod. 2018 Nov; 48 (Epub 2018 Sep 14. PMID: 30450327; PMCID: PMC6234113): 349-356
        • Oh SH
        • Nahm KY
        • Kim SH
        • Nelson G.
        Alveolar bone thickness and fenestration of incisors in untreated Korean patients with skeletal class III malocclusion: a retrospective 3-dimensional cone-beam computed tomography study.
        Imaging Sci Dent. 2020 Mar; 50 (Epub 2020 Mar 17. PMID: 32206615; PMCID: PMC7078404): 9-14
        • Nahm KY
        • Kang JH
        • Moon SC
        • Choi YS
        • Kook YA
        • Kim SH
        • et al.
        Alveolar bone loss around incisors in Class I bidentoalveolar protrusion patients: a retrospective three-dimensional cone beam CT study.
        Dentomaxillofac Radiol. 2012; 41: 481-488
        • Lu CL
        • Li BW
        • Yang M
        • Wang XQ
        Relationship between alveolar-bone morphology at the mandibular incisors and their inclination in adults with low-angle, skeletal class III malocclusion—a retrospective CBCT study.
        PLOS ONE. 2022; 17e0264788
        • Kim Y
        • Park JU
        • Kook YA.
        Alveolar bone loss around incisors in surgical skeletal Class III patients.
        Angle Orthod. 2009 Jul; 79 (PMID: 19537864): 676-682
      1. Yao CJ, Chang ZC, Lai HH, Hsu LF, Hwang HM, Chen YJ. Architectural changes in alveolar bone for dental decompensation before surgery in Class III patients with differing facial divergence: a CBCT study. Sci Rep. 2020 Sep 1;10(1):14379. doi: 10.1038/s41598-020-71126-3. PMID: 32873841; PMCID: PMC7463229.

        • Chen K
        • Han X
        • Huang L
        • Bai D.
        Tooth movement after orthodontic treatment with 4 second premolar extractions.
        Am J Orthod Dentofacial Orthop. 2010 Dec; 138 (PMID: 21130336): 770-777
        • Chang CH
        • Lin LY
        • Roberts WE.
        Orthodontic bone screws: A quick update and its promising future.
        Orthod Craniofac Res. 2021 Mar; 24 (Epub 2020 Nov 23. PMID: 33225592): 75-82
        • Chang C
        • Liu SS
        • Roberts WE.
        Primary failure rate for 1680 extra-alveolar mandibular buccal shelf mini-screws placed in movable mucosa or attached gingiva.
        Angle Orthod. 2015 Nov; 85 (Epub 2015 Jan 20. PMID: 25603272; PMCID: PMC8612035): 905-910
        • Kook YA
        • Park JH
        • Bayome M
        • Kim S
        • Han E
        • Kim CH.
        Distalization of the mandibular dentition with a ramal plate for skeletal Class III malocclusion correction.
        Am J Orthod Dentofacial Orthop. 2016 Aug; 150 (PMID: 27476370): 364-377
        • Jung MH.
        A comparison of second premolar extraction and mini-implant total arch distalization with interproximal stripping.
        Angle Orthod. 2013 Jul; 83 (Epub 2012 Nov 30. PMID: 23199101; PMCID: PMC8754042): 680-685
        • Song B.-J.
        • Lee K.-J.
        • Cha J.-Y.
        • Lee J.-S.
        • Mo S.-S.
        • Yu H.-S.
        Stability of the maxillary and mandibular total arch distalization using temporary anchorage devices (TADs) in adults.
        Appl. Sci. 2022; 12: 2898
        • SY Jo
        • Bayome M
        • Park J
        • Lim HJ
        • Kook YA
        • Han SH.
        Comparison of treatment effects between four premolar extraction and total arch distalization using the modified C-palatal plate.
        Korean J Orthod. 2018 Jul; 48 (Epub 2018 Jul 6. PMID: 30003056; PMCID: PMC6041454): 224-235
      2. Wang D, Yan Y, Wang C, Qian Y. [Three-dimensional finite element analysis of the biomechanical effects of multiloop edgewise archwire (MEAW)]. Sheng Wu Yi Xue Gong Cheng Xue Za Zhi. 2005 Feb;22(1):86-90. Chinese. PMID: 15762123.

        • Venugopal A.
        • Ghoussoub M.S.
        • Manzano P.
        • et al.
        Molar protraction on an adult with severe high-angle class III malocclusion and knife-edge residualridges.
        OrthodonticWaves. 2021; : 1-9
        • Rozzi M
        • Mucedero M
        • Pezzuto C
        • Cozza P.
        Leveling the curve of Spee with continuous archwire appliances in different vertical skeletal patterns: A retrospective study.
        Am J Orthod Dentofacial Orthop. 2017 Apr; 151 (PMID: 28364900): 758-766
        • Pepicelli AJ
        • Woods MG
        • Briggs C.
        The mandibular muscles and their importance in contemporary orthodontics: a review.
        Am J Orthod Dentofac Orthop. 2005; 128 ([Crossref], [Web of Science ®], [Google Scholar]): 775-780
        • Gomes SG
        • Custodio W
        • Jufer JS
        • et al.
        Mastication, EMG activity and occlusal contact area in subjects with different facial types.
        Cranio. 2010 Oct; 28 ([Taylor & Francis Online], [Web of Science ®], [Google Scholar]): 274-279
        • Seok H
        • Kim SG
        Correction of Malocclusion by Botulinum Neurotoxin Injection into Masticatory Muscles.
        Toxins (Basel). 2018 Jan 2; 10 (PMID: 29301317; PMCID: PMC5793114): 27
        • Hagberg C.
        Electromyography and bite force studies of muscular function and dysfunction in masticatory muscles.
        Swed Dent J Suppl. 1986; 37 ([Google Scholar]): 1-64
        • Manns A
        • Valdivieso C
        • Rojas V
        • et al.
        Comparison of clinical and electromyographic rest vertical dimensions in dolichofacial and brachyfacial young adults: a cross-sectional study.
        J Prosthet Dent. 2018 Oct; 120 ([Crossref], [Web of Science ®], [Google Scholar]): 513-519
        • Rozzi M
        • Mucedero M
        • Pezzuto C
        • Lione R
        • Cozza P.
        Long-term stability of curve of Spee levelled with continuous archwires in subjects with different vertical patterns: a retrospective study.
        Eur J Orthod. 2019 May 24; 41 (PMID: 30289476): 286-293
        • Shannon KR
        • Nanda RS.
        Changes in the curve of Spee with treatment and at 2 years posttreatment.
        Am J Orthod Dentofacial Orthop. 2004 May; 125 (PMID: 15127028): 589-596
        • Canut J.A.
        • Arias S.
        A long-term evaluation of treated Class II division 2 malocclusions: a retrospective study model analysis.
        Eur J Orthodont. 1999; 21: 377-386
        • Bertl K
        • Neuner H
        • Meran A
        • Bertl MH
        • Reich I
        • Nemec M
        • Bruckmann C
        • Stavropoulos A
        • Bantleon HP.
        Does the time-point of orthodontic space closure initiation after tooth extraction affect the incidence of gingival cleft development? A randomized controlled clinical trial.
        J Periodontol. 2020 May; 91 (Epub 2019 Oct 17. PMID: 31559633; PMCID: PMC7317775): 572-581
        • Reichert C
        • Kutschera E
        • Plötz C
        • Scharf S
        • Gölz L
        • Fimmers R
        • Fuhrmann C
        • Wahl G
        • Braumann B
        • Jäger A.
        Incidence and severity of gingival invaginations associated with early versus late initiation of orthodontic space closure after tooth extraction: A multicenter pilot and randomized controlled trial.
        J Orofac Orthop. 2017 Sep; 78 (EnglishEpub 2017 Jun 28. PMID: 28660421): 415-425
        • Robertson PB
        • Schultz LD
        • Levy BM.
        Occurrence and distribution of interdental gingival clefts following orthodontic movement into bicuspid extraction sites.
        J Periodontol. 1977 Apr; 48 (PMID: 265393): 232-235
        • Wehrbein H
        • Bauer W
        • Diedrich PR.
        Gingival invagination area after space closure: a histologic study.
        Am J Orthod Dentofacial Orthop. 1995 Dec; 108 (PMID: 7503036): 593-598
        • Proffit WR
        • Fields HW
        • Sarver DM.
        Contemporary Orthodontics.
        4th ed. Mosby Inc, St.Louis, MO, USA2007
        • Melsen Dr., B
        Birte Melsen on adult orthodontic treatment. Interview by Vittorio Cacciafesta.
        J Clin Orthod. 2006 Dec; 40: 703-716
        • Kim SH
        • Cha KS
        • Lee JW
        • Lee SM.
        Mandibular skeletal posterior anatomic limit for molar distalization in patients with Class III malocclusion with different vertical facial patterns.
        Korean J Orthod. 2021; 51: 250-259
        • Verna C.
        Regional acceleratory phenomenon.
        Front Oral Biol. 2016; 18 (Epub 2015 Nov 24. PMID: 26599115): 28-35
        • Ahn HW
        • Ohe JY
        • Lee SH
        • Park YG
        • Kim SJ.
        Timing of force application affects the rate of tooth movement into surgical alveolar defects with grafts in beagles.
        Am J Orthod Dentofacial Orthop. 2014 Apr; 145 (PMID: 24703287): 486-495
        • Hirabayashi M
        • Motoyoshi M
        • Ishimaru T
        • Kasai K
        • Namura S.
        Stresses in mandibular cortical bone during mastication: biomechanical considerations using a three-dimensional finite element method.
        J Oral Sci. 2002 Mar; 44 (PMID: 12058864): 1-6
        • Mangla R
        • Singh N
        • Dua V
        • Padmanabhan P
        • Khanna M.
        Evaluation of mandibular morphology in different facial types.
        Contemp Clin Dent. 2011 Jul; 2 (PMID: 22090764; PMCID: PMC3214527): 200-206
      3. Venugopal A. Whole-arch distalization using extraradicular miniscrews to correct lip incompetence and bidental protrusion. Online at (accessed on 15th October 2022)

        • Park HS
        • Lee SK
        • Kwon OW.
        Group distal movement of teeth using microscrew implant anchorage.
        Angle Orthod. 2005; 75: 602-609
        • Almeida MR.
        Biomechanics of extra-alveolar mini-implants.
        Dental Press J Orthod. 2019 Sep 5; 24 (PMID: 31508712; PMCID: PMC6733231): 93-109
        • Oh YH
        • Park HS
        • Kwon TG.
        Treatment effects of microimplantaided sliding mechanics on distal retraction of posterior teeth.
        Am J Orthod Dentofacial Orthop. 2011; 139: 470-481
        • Ye C
        • Zhihe Z
        • Zhao Q
        • Ye J.
        Treatment effects of distal movement of lower arch with miniscrews in the retromolar area compared with miniscrews in the posterior area of the maxillary.
        J Craniofac Surg. 2013 Nov; 24 (PMID: 24220385): 1974-1979
        • Ahn J
        • Kim SJ
        • Lee JY
        • Chung CJ
        • Kim KH.
        Transverse dental compensation in relation to sagittal and transverse skeletal discrepancies in skeletal Class III patients.
        Am J Orthod Dentofacial Orthop. 2017 Jan; 151 (PMID: 28024769): 148-156 031
        • Primozic J
        • Farcnik F
        • Perinetti G
        • Richmond S
        • Ovsenik M.
        The association of tongue posture with the dentoalveolar maxillary and mandibular morphology in Class III malocclusion: a controlled study.
        Eur J Orthod. 2013 Jun; 35 (Epub 2012 Mar 30. PMID: 22467568): 388-393
        • Hu X
        • Huang X
        • Gu Y.
        Assessment of buccal and lingual alveolar bone thickness and buccolingual inclination of maxillary posterior teeth in patients with severe skeletal Class III malocclusion with mandibular asymmetry.
        Am J Orthod Dentofacial Orthop. 2020 Apr; 157 (PMID: 32241357): 503-515
        • Yu J
        • Hu Y
        • Huang M
        • Chen J
        • Ding X
        • Zheng L
        A three-dimensional analysis of skeletal and dental characteristics in skeletal class III patients with facial asymmetry.
        J Xray Sci Technol. 2018; 26 (PMID: 29562577): 449-462
        • Garib DG
        • Henriques JF
        • Janson G
        • de Freitas MR
        • Fernandes AY.
        Periodontal effects of rapid maxillary expansion with tooth-tissue-borne and tooth-borne expanders: a computed tomography evaluation.
        Am J Orthod Dentofacial Orthop. 2006 Jun; 129 (PMID: 16769493): 749-758
        • Suzuki H
        • Moon W
        • Previdente LH
        • Suzuki SS
        • Garcez AS
        • Consolaro A.
        Miniscrew-assisted rapid palatal expander (MARPE): the quest for pure orthopedic movement.
        Dental Press J Orthod. 2016 Jul-Aug; 21 (PMID: 27653260; PMCID: PMC5029312): 17-23
        • Cao L
        • Zhang K
        • Bai D
        • Jing Y
        • Tian Y
        • Guo Y.
        Effect of maxillary incisor labiolingual inclination and anteroposterior position on smiling profile esthetics.
        Angle Orthod. 2011 Jan; 81 (PMID: 20936964; PMCID: PMC8926362): 121-129
        • Jeelani W
        • Fida M
        • Shaikh A.
        The maxillary incisor display at rest: analysis of the underlying components.
        Dental Press J Orthod. 2018 Nov-Dec; 23 (PMID: 30672985; PMCID: PMC6340193): 48-55
        • Paik CH
        • Woo YJ
        • Boyd R.
        Non-surgical treatment of an adult skeletal Class III patient with insufficient incisor display.
        J Clin Orthod. 2005 Sep; 39 (quiz 531. PMID: 16244414): 515-521
        • Roberts WE
        • Viecilli RF
        • Chang C
        • Katona TR
        • Paydar NH.
        Biology of biomechanics: Finite element analysis of a statically determinate system to rotate the occlusal plane for correction of a skeletal Class III open-bite malocclusion.
        Am J Orthod Dentofacial Orthop. 2015 Dec; 148 (PMID: 26672700): 943-955
        • Venugopal A
        • Manzano P
        • Srirengalakshmi M
        • Marya A
        • Vaid NR
        • Bowman SJ.
        Physiologic midtreatment tooth movement as a correction strategy for iatrogenic root exposure.
        Case Rep Dent. 2020 Sep 5; 2020 (PMID: 32963842; PMCID: PMC7492963)8841009
      4. Kim J, Clark D. Full-mouth black triangle treatment protocol. Dentistry Today. 2017;72–77.

        • Burke S.
        • Burch J.G.
        • Tetz J.A.
        Tetz JA. Incidence and size of pretreatment overlap and post treatment gingival embrasure space between maxillary central incisors.
        Am J Orthod Dentofacial Orthop. 1994; 105: 506-511
        • Lin Y.H.
        • Lin J.S.
        • Chang C.
        • Roberts W.E.
        Treatment of a Class I Bimaxillary Protrusion, Crowding, and Black Triangles.
        JDO. 2022; 68: 26-41