Orthodontic camouflage as a treatment alternative for skeletal Class III

ABSTRACT Introduction: Skeletal Class III malocclusion is a deformity of complex treatment, with few intervention alternatives, which are further limited in nongrowing patients. In most cases, orthognathic surgery is the ideal treatment for adults, an option often refused by patients. Mild to moderate skeletal Class III malocclusions and acceptable facial esthetics can benefit from a course of treatment in which dental movements are used to compensate for the skeletal discrepancy. Objective: This study aimed to discuss orthodontic camouflage as an option for adult patients with Class III malocclusion, emphasizing its indications, implications and expected results.


INTRODUCTION
Skeletal Class III malocclusion is one of the most challenging problems faced by orthodontists. 1,2 It is characterized by an anteroposterior discrepancy between the maxilla and the mandible usually associated with dentoalveolar compensation (protruded maxillary incisors and/or proclined and retroclined mandibular incisors), to maintain the function and camouflage the existing skeletal discrepancy. 3 Compromised facial esthetics is often present, constituting, in these cases, the main reason why patients or their guardians seek treatment. 4 In adult patients, treatment is more complex due to the limited options available. 5 In most cases, orthodontic treatment combined with orthognathic surgery is often the ideal treatment. However, many patients refuse the surgical option due to its cost or the invasive nature of the procedure. 6,7 Nongrowing patients with mild to moderate skeletal Class III malocclusion and acceptable facial esthetics can benefit from camouflage orthodontic treatment, 3 to enable the displacing of teeth relative to their supporting bone to compensate for an underlying jaw discrepancy. It is indicated when growth modification to overcome the basic problem is not feasible. 1 The objectives of camouflage treatment include attaining acceptable occlusion, function, and esthetics through dentoalveolar compensation for the skeletal discrepancy. 8 Camouflage treatment was introduced into orthodontics in the 1930s and 1940s, when extraction to camouflage a skeletal malocclusion became popular, as growth modification had been widely regarded as ineffective, and surgical correction was still in early development. The strategy to camouflage a Class III malocclusion usually involves proclination of the maxillary incisors and retroclination of the mandibular incisors, to improve dental occlusion, although it might not correct the skeletal problem or facial profile. 1 In patients with moderate skeletal Class III malocclusion, the decision for orthodontic camouflage as a treatment option should consider some parameters. First, the extent of compromise of facial esthetics must be assessed and how important this is for the patient. In cases of significant esthetic complaint, orthognathic surgery is required. 9,10 The second parameter is the anteroposterior position and inclination of maxillary and mandibular incisors, and whether their orthodontic movement is sufficient for correcting the malocclusion. The third parameter is the thickness of mandibular symphysis, which should allow extensive incisor retraction. Finally, the degree of anteroposterior discrepancy must also be assessed. Even if facial esthetics is acceptable, the symphysis is thick enough, and the mandibular incisors are favorably inclined, camouflage will not be indicated if the anteroposterior discrepancy is too severe. 10,11 The initial positioning of maxillary and mandibular anterior teeth, and mandibular growth are unfavorable for the nonsurgi-    Table 1).

TREATMENT PLAN AND MECHANICS USED
Since he was satisfied with his facial esthetics, the patient was contrary to any surgical intervention to treat the skeletal Class III malocclusion. Therefore, the chosen treatment was orthodontic camouflage, with the extraction of tooth #15 followed by the loss of upper anchorage and extraction of the first mandibular premolars, maintaining maximum anchorage for the retraction of the anterior teeth without modifying the positions of teeth #36 and #46.
Araujo MTS, Squeff LR -Orthodontic camouflage as a treatment alternative for skeletal Class III  was placed (removed seven years later). After removing these appliances, no retention device was installed, and the patient was followed up annually.

TREATMENT RESULTS
The orthodontic treatment performed had its objectives achieved and provided functional and esthetic improvements.
The deficiency of the middle third remained, as well as the facial asymmetry, but they remained discreet. The buccal corridor

DISCUSSION
Patients with severe Class III skeletal deformity are often candidates for orthognathic surgery as the only choice toward normal occlusion and an esthetic profile. 14 However, the dilemma lies in the fact that most patients reject surgical therapy, persisting in orthodontic treatment. Moreover, the facial profile of Class III skeletal deformities is always the primary concern of these patients when seeking treatment. This truly is a great challenge for orthodontists, and estimating facial Due to the relationship between age, growth, and development, early intervention methods cannot be applied to treat skeletal deformities in the permanent dentition or in adults.
From this perspective, the only non-surgical alternative to manage skeletal deformities in the permanent dentition or in the adult is comprehensive treatment with fixed appliances. 8 Nongrowing patients with moderate skeletal Class III malocclusion and acceptable facial esthetics can benefit from orthodontic camouflage, 16 especially in cases of mild to moderate skeletal discrepancies. 11 In the present case, which involved an adult patient with problems in the three planes (anteroposterior, vertical, and transverse) and indication for ortho-surgical treatment (option refused by the patient), orthodontic camouflage was chosen even with the limitations imposed by this choice (skeletal problems would not be corrected).
Despite the dissatisfaction with his smile esthetics, the patient showed a good appearance and was not bothered by his profile, which influenced his emphatic negative position regarding surgical correction. The decision for orthognathic surgery is mainly related to the self-perception of patients. 17 Although dental specialists may recommend surgical treatment, self-perceptions of the facial profile are more important in the patient's decision to choose this type of treatment. 9 The results obtained with orthodontic camouflage were The retroclination of mandibular incisors in the camouflage treatment can result in prominent (vestibular) roots and gingival recessions. Therefore, care must be taken to attain a proper dentoskeletal relationship, especially in cases of severe skeletal dysplasias. 3 Accordingly, the present patient was treated with great care, as he already showed significant gingival recession in tooth #33. The problem was monitored throughout treatment, and periodontal care was recommended, with rigorous dental plaque control. Canine distalization and incisor retraction were carefully performed, to maintain the normal gingival insertion levels of the incisors and prevent the increase of recession in tooth #33. Results showed that these procedures were effective, continuing throughout the retention phase (Figs 4 and 7).

Luciana Rougemont Squeff (LRS)
Conception or design of the study:

MTA.
Data acquisition, analysis or interpretation:

MTA, LRS.
Writing the article:

MTA, LRS.
Critical revision of the article:

MTA, LRS.
Final approval of the article:

MTA.
Patients displayed in this article previously approved the use of their facial and intraoral photographs.
The authors report no commercial, proprietary or financial interest in the products or companies described in this article.