Non - Surgical Management of A Borderline Skeletal Class III Malocclusion Using Buccal Shelf Bone Screws: A Case Report
Dr. V. Sonavarshini 1, Dr. Pawan Kumar Bhandari*
*Correspondence to: Dr. Pawan Kumar Bhandari, Professor, Department of Orthodontics, Vivekananda dental College.
Copyright.
© 2026 Dr. Pawan Kumar Bhandari, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received: 22 August 2026
Published: 01 September 2026
DOI: https://doi.org/10.5281/zenodo.22269881
Abstract
A developing class III malocclusion can be treated by growth modification using facemask or chincup in young ages. After growth completion the treatment option is either camouflage or surgical approach. With the advent of miniscrews, the camouflage treatment can be done without extraction of premolars and the borderline surgical cases can also be corrected using miniscrews to achieve stable results. This is a case report of 20 year old female who presented with a class III malocclusion with prognathic mandible, lower anterior crowding and midline diastema with a reverse overjet of 2 mm. The treatment was carried out by distalising the mandible using buccal shelf screws of size 2 × 10 mm using e-chain. The total treatment time was 17 months and treatment was finished with lingual bonded retainer from canine to canine in upper and lower arches. A stable and a good functional occlusion with pleasing esthetics were obtained.
Keywords: Buccal shelf, Bone screw, Mandibular prognathism, Distalisation
Introduction
Malocclusions are ranked by the World Health Organization as the third most common oral health issue, after periodontal diseases and dental caries [1]. The prevalence and appearance of class III malocclusion are also influenced by gender and ethnicity, with East Asian people exhibiting greater rates of 19.9% of worlds’ total population and hormonal effects affecting male and female craniofacial development. Class III malocclusion was found to be highest in permanent dentition than the primary and mixed dentition. The class III malocclusion was found to be due to the mid face deficiency rather than mandibular prognathism in the Caucasian race. [2], [3]. Certain characteristics often observed in skeletal class III malocclusion include maxillary deficiency, mandibular excess, or a combination of both. The forward positioning of the maxillary incisors and the backward positioning of the mandibular teeth is found as a dentoalveolar compensation [4].
The treatment modality for a skeletal class III is usually orthognathic surgery or dentoalveolar adjustments. Patients with mild-to-moderate Class III malocclusion who have finished their primary growth and have no significant skeletal asymmetry can be a good candidate for camouflage treatment, which focuses on improving dental occlusion and aesthetics without addressing underlying skeletal deformities. This approach involves nonsurgical orthodontics and requires careful consideration of pretreatment dental adjustments to prevent issues like gingival recession and root resorption. In mild to moderate skeletal Class III discrepancies, camouflaging provides better esthetics by hiding the skeletal problems and helps to obtain a good occlusion [5]. Patients with severe skeletal asymmetry, large negative overjet, or high-profile improvement expectations have to undertake surgical treatment. There have been many significant developments in orthodontics over the past century. The use of buccal shelf (BS) orthodontic bone screws has helped to mask the skeletal discrepancy and plays an excellent role in camouflaging. [6]
This case report demonstrates the orthodontic camouflage treatment in a Class III malocclusion patient using buccal shelf bone screws. The clinical management of an adult skeletal and dental Class III malocclusion complicated by a right-shifted midline is treated conservatively, and a satisfactory outcome was obtained.
Case Presentation
A 20-year-old female patient reported with a chief complaint of irregular bite in front jaw. There was no relevant medical and dental history. On clinical examination the patient had a leptoproscopic face with a concave profile, positive lip-step, anterior divergence, protruded chin and competent lips. On smile analysis, the patient showed symmetrical smile with a flat smile arc, low lip line and an increased buccal corridor space. On intra-oral examination all the compliments of teeth present, Angle Class III molar relationship bilaterally, midline diastema in upper arch, the lower arch showed a very mild degree of crowding, anterior crossbite present, lower dental midline shifted toward right side by 2 mm. A reverse overjet of 2 mm was seen. Cephalometric examination and analysis showed the skeletal Class III tendency, with retrognathic maxilla and prognathic mandible, vertical mandibular plane angle with proclined and protruded maxillary incisors and retroclined mandibular incisors. Panoramic radiograph showed an impaction of 28 and missing of 18 and 48. Other teeth were present without any pathological findings. No abnormal findings were noted. The patient was diagnosed with, Angle Class III malocclusion on class III skeletal base with retrognathic maxilla and prognathic mandible with midline diastema and lower anterior crowding and lower dental midline shift to right.
Treatment Objectives:
Treatment alternatives:
The patient was first advised for orthognathic surgery to correct the mandibular protrusion. The second treatment alternative was En masse distalisation of the mandibular teeth using the buccal shelf screws. Since the patient was not willing for the orthognathic surgery, the second option was considered.
Treatment plan:
A fixed mechanotherapy using MBT 0.022 inch slot was planned (Bonding from 7-7). The anterior crossbite was planned to be corrected by opening the bite with the help of bite block and negative overjet will be corrected by distalizing the mandibular dentition. After the desired amount of overjet is achieved, settling of posterior occlusion would be done. The midline diastema would later be closed along with midline correction.
Retention plan:
The retention plan was fixed Lingual bonded retainers from 3-3 in the upper and lower arches.
Treatment progress:
Phase I: Initial alignment and the leveling of upper and lower arch was done using 0.014”, 0.016”, 16 ×22” , 17 × 25” nickel titanium (NiTi) wires followed by, 19 x 25” NiTi and 19 x 25”SS wires. The alignment stage was 6 months. 38 was planned for extraction before the commencement of distalization of mandibular dentition. Phase II: The lower arch was consolidated and after 2 months, 2x10-mm Buccal Shelf stainless steel screw (SK surgicals, India) was placed bilaterally on the buccal shelf region.
A force of 150-g was applied bilaterally from the screws to the power arms soldered to 19 x 25”SS using a closed elastomeric chain (GAC, Dentsply). After 7 months of force application, the distalization of mandibular dentition was completed. Phase III: The final finishing and detailing was done using 0.014 NiTi archwire and with settling elastics. The total treatment time was 17 months.
Treatment Results:
The patient’s soft tissue profile has improved. Anterior crossbite and the lower arch crowding were corrected. Midline shift was also corrected. Angle’s Class I molar and canine relationship were obtained. Root parallelism was achieved. There were no signs of root resorption. Normal overjet and overbite with stable occlusion and a good intercuspation were achieved. The patient’s profile improved with pleasing aesthetics.
|
Cephalometric variables |
Standard values |
Pre – treatment values |
Post – treatment values |
|
SNA |
82 º +/-2º |
80 º |
81 º |
|
SNB |
82 º +/-2 º |
82 º |
80 º |
|
ANB |
2 º |
-2 º |
1 º |
|
Lower incisor to NB (mm/deg)- |
4 mm/25 º |
7 mm/26? |
5 mm/24? |
|
Upper incisor to NA (mm/deg)- |
4 mm /22 º |
7 mm/33? |
7 mm/35? |
|
Overjet |
2- 4 mm |
-2 mm |
2 mm |
|
Overbite |
2- 4 mm |
4 mm |
3mm |
|
Frankfort mandibular plane angle |
25 º |
27 º |
28 º |
|
Mandibular Length–effective |
120+/- 4.5 mm |
113 mm |
107 mm |
|
Lower lip to Ricketts’ E plane |
-2+/-2mm |
-1 mm |
- 2 mm |
|
Nasolabial angle |
102 º +/-8 º |
78 º |
93 º |
Table 1: Comparison of cephalometric values
Discussion
In this case, the entire mandibular dentition was distalized with E-chain from the power arm hooked distal to the canine to the buccal shelf screw without extrusion or forward movement of maxillary dentition. Mandibular distalization preceded with NiTi wire for anterior decrowding. After distalization and decrowding, the midline diastema was closed with an E-chain. The implant placement site was based on the anatomic structures, cortical bone thickness, and soft-tissue functional movements.
Reports suggest that the suitable site for distalization with skeletal anchorage is distal to the last erupted molar [8, 9]. But the problem is that, soft-tissue irritation occurs around the implants because of the thickness and more movable tissue than in other areas. This can result in inflammation, patient discomfort, and difficulty applying elastics or NiTi coil springs. [10] Miniscrews can also be placed between roots of the posterior teeth without damaging their roots, because the cortical bone in those areas is thick. In this case, the mandibular dentition was distalized to 6mm on left side and 4 mm on right side. In literature, the amount of molar distalisation that is achieved with the aid of mini-implants varies between 2-6 mm. Poletti et al reported molar distalization of 4 mm with a 10? tipping. [11] Sugawara et al. has achieved mandibular molar distalization of 1.8 mm at the root level and 3.5 mm at the crown level. [12]
Distalization of the mandibular dentition caused a slight mandibular posterior extrusion, which is quite unfavorable in high angle patients. In this case at the end of distalization there was 1º increase of the mandibular plane angle. Because the distalizing force from the buccal shelf miniscrews crosses the center of resistance of the mandibular dental arch, it causes the mandible to rotate counterclockwise.
Regarding the transverse dimension, buccally directed force caused molars to roll in [6]. In this case the lingual roll - in of the molars were prevented by placing an expanded arch form in the molar region. When used in Class III malocclusion instances, the buccal shelf miniscrew-supported mandibular arch distalization therapy provides a beneficial alternative since it removes the negative consequences of alternative camouflage treatment choices.
Conclusion
Skeletal class III malocclusion was corrected by camouflaging. The mandible dentition was distalised en mass using the stainless buccal shelf screws of size 2 × 10 mm. the treatment duration was 17 months wherein the disalization was done for 7 months. At the end, Class I molar and canine relationship was achieved with ideal overjet and overbite.
References