Advantages of using micro-implant during camou ﬂ aged treatment of the non-growing Class III malocclusion: case report with in-detail discussion

Background. Camou ﬂ aged orthodontic treatment as a possible rehabilitation algorithm may be proposed for the Class III malocclusion patients without remaining growth potential. Objective. To discuss clinically signi ﬁ cant aspects of providing camou ﬂ aged orthodontic treatment for the non-growing Class III malocclusion with the usage of temporary-anchorage devices based on presented clinical case. Materials and Methods. Primary cohort of the publications related with the camou ﬂ aged treatment of the non-growing Class III malocclusion was formed through the literature search within PubMed database using MESH-terms and the analogical keywords within Google Scholar search engine. Results. In present case report it was possible to achieve pleasant facial pro ﬁ le, and Class I occlusion with normal anterior-posterior relationships in patient with initial Class III malocclusion. The mandible arch length de ﬁ ciency was corrected within the mandibular dentition, and normal alignment was achieved without altering the arch form and width parameter due to the use of Class III elastics and micro-implants as absolute anchorage. Systematized advantages of using skeletal anchorage for Class III orthodontic treatment include following: minimized drawback of dental-based anchorage, possibility for greater maxillary advancement, maximization of skeletal effect and minimization of clockwise mandible rotation, forming conditions for elastics wear during whole day with possibility to employ smaller traction forces, while minimizing risk of unwanted changes in any craniofacial structures. Conclusion. Camou ﬂ aged orthodontic correction is a reliable treatment option for Class III malocclusion patients without remaining growth potential. Micro-implants as skeletal anchorage devices represent reliable opportunity for camou ﬂ aged orthodontic treatment of Class III malocclusion patients and


Introduction
Due to the systematic review prevalence of Class III malocclusion could reach up to 26.7% in different population samples [1]. Recent assessment of different malocclusion traits prevalence worldwide revealed that Class III malocclusion prevalence is in the range of 1-20% within permanent dentition [2]. Development of Class III malocclusion may be contributed by the several factors and conditions: normal position and size of the maxilla, but with prognathic or macrognathic mandible; normal position and size of mandible, but with retrognathic or micrognathic maxilla; combination of two above-mentioned variants; reverse overjet under condition of centric relation-centric occlusion discrepancies even though skeletal jaw relationship is normal (pseudo-Class III malocclusion) [3].
Despite the fact that Class III remains the least prevalent malocclusion pattern compared to Class I and Class II, cases of such represent clinically complicated situations for treatment. Orthopedic approaches for Class III malocclusion impact residual growth of maxilla-facial structures and recommended for children and adolescents with present growth potential, but only limited number of treatment options available for non-growing patients with Class III malocclusion [4,5,6,7,8].
Due to the previously proposed classifi cation orthognathic surgery, temporary anchorage device-based treatment and camoufl age approaches including extractions may be used for the following categories of Class III malocclusion patients with limited or no growth potential: Class III Type 4 (prognathic mandible Class III), Class III Type 5 (retrognathic maxilla and prognathic mandible), Class II Type 6 (bimaxillary), Class II Type 7 (craniofacial malformations) [3].
Orthognathic surgery remains ideal solution for Class III malocclusion in adult patients from the functionally-and pathogenetically targeted points of view, but still there is a number of surgery-related disadvantages of such kind of intervention [5,6,7,9]. https Camoufl aged orthodontic treatment as a possible rehabilitation algorithm may be proposed for the Class III malocclusion patients without remaining growth potential. Such approach is based on attempt to «conceal» skeletal malocclusion by interventions targeted on receiving partial correction through dento-alveolar compensation. Latter frequently associated with the retroclination of lower anterior teeth and proclination of maxillary incisors [7,9].
As per orthodontic specialists' opinion orthodontic treatment of Class III characterized with signifi cantly higher chances of pathology relapses, meanwhile post-operative complication rates for this treatment method could be minimal. On the other hand, combined orthodontic and orthognathic treatment of Class III malocclusion associated with greater chance to achieve close to ideal Class I relationship in shorter period of time [10].
Nevertheless, it should be kept in mind that fi nal agreement regarding different treatment approaches that can be used for nongrowing Class III malocclusion relies on the patients themselves, who frequently are scared of orthognathic operations, and tend to choose camoufl age orthodontic approach to normalize facial profi le and partially correct occlusal interrelations.

Objective
To discuss clinically signifi cant aspects of providing camoufl aged orthodontic treatment for the non-growing Class III malocclusion with the usage of temporary-anchorage devices based on presented clinical case.

Literature review
Primary cohort of the publications related with the camoufl aged treatment of the non-growing Class III malocclusion was formed through the literature search within PubMed database using MESH-terms and the analogical keywords within Google Scholar search engine. Only studies written in English or at least with English abstract representing key fi ndings were included into the study cohort, while no other exclusion criteria were used. There was no need for implementing any criteria regarding quality of selected publications as inclusion ones since objective of the literature search was just to gather maximum volume of the data regarding camoufl aged treatment of the non-growing Class III malocclusion.
After reduction of primary cohort of publications by excluding studies, which were not associated with presented clinical case and formulated objective, remained publications included into study sample undergone relational content-analysis with using following topics of interest as research categories [11]: • decision-making of providing either surgical or orthodontic camoufl aged treatment for the non-growing Class III malocclusion cases; • advantages, limitation, and specifi cs of providing non-growing Class III malocclusion patients with orthodontic camoufl aged treatment; • reasonability of using micro-implants as temporary anchorage devices during camoufl aged treatment of the non-growing Class III malocclusion cases.
Data extraction was provided in incremental manner and structured due to the above-mentioned categories [11]. Relations among structured data complexes was assessed with the use of ER models principles with the following entities: criteria used for the argumentation of orthodontic camoufl aged treatment provision among non-growing Class III malocclusion patients, clinicallyreasoned advantages and specifi cs of camoufl aged treatment approach in cases of Class III malocclusion, role and signifi cance of micro-implants within orthodontic camoufl aged treatment protocol used for Class III malocclusion cases and alternatives of such.

Clinical case presentation
A 16-years and two-month-old boy was brought into the dental clinic by his parents for evaluation of his dentofacial appearance. Medical history revealed mouth breathing since early childhood. During clinical examination it was found that patient exhibited skeletal Class III malocclusion and low position of the tongue (Figure 1-3).
There was no previous history of dental trauma or bad oral habits. The dentition was crowded in the anterior mandible, and bilateral cross bite was observed in the maxilla region. No signifi cant signs or symptoms of temporomandibular disorders were noted during in-detail clinical examination. Range of mandibular movements and amount of mouth opening were categorized as normal.
Patient's face was symmetrical with normal lip competence. During smile a full display of incisors and disharmony in the posterior teeth were noted. Patient had a concave profi le with high vertical lower facial dimension, and 2 mm reversed overjet and no overbite. Dental midline deviated 2 mm to the right from the facial midline.
Orthopantomography revealed complete dentition including third molars in the left side of maxilla and right side of mandible ( Figure 5).
Based on the clinical examination and anamnesis it was resumed that the etiology of the malocclusion was genetic. It was presumed that Class III and maxillary arch deformation were sequelae of skeletal Class III (brachyfacial pattern).

Problem list
1. Soft tissues: concave profi le 2. Skeletal: brachyfacial pattern, mandibular prognathic position 3. Dental: Class III relationship with midline deviation Treatment objectives • Facial esthetics objectives: to obtain balanced profi le and a normal Z angle.
• Functional objectives: to arrange all the teeth and achieve optimal functional effi ciency within Class I occlusion with normal overbite and overjet.
• Dentition objectives: to arrange correct teeth position for positive periodontal and TMJ prognosis.
• Stability objectives: to position and arrange teeth for maximum stability of obtained treatment results.

Treatment plan
Treatment was realized in two phases. Phase 1: Crossbite correction (rapid maxillary expansion), transpalatal bar, frenectomy (for low tongue position) Phase 2: placement of micro-implant in maxilla between premolar and molar upper and use of Class III elastics (for lower dentition distalization)
Initial alignment begun with Ni-Ti archwire, and distal force was applied from micro-implant by connecting super thread (T-45 Dentos, Co Daegu, Korea) to the mandibular canine. The purpose of this force was to prevent round trip movement of anterior mandibular teeth during initial alignment.
After 2 months of treatment alignment was completed, and 0.16×0.25 mm SS archwires were inserted at maxilla and mandible, respectively. After 5 months of treatment 0.17×0.25 mm SS archwire with a hook was inserted and elastics 5/16 (5 oz) were placed from the microimplant in the maxilla to provide distal force to canine in the mandible. Elastics were used for 18-24 hours per day excluding mealtime.
After 7 months of treatment, 0.17×0.25 mm archwire was inserted at the maxilla and 0.18×0.25 mm archwire was inserted at the mandible, while Class III elastics were continuously used. After 9 months of treatment 0.18×0.25 mm archwire was inserted at the maxilla and 0.19×0.25 mm archwire was inserted at the mandible, while Class III elastics were continuously used. After 15 months of treatment maxillary and mandibular dental midline were coincided and proper overjet and alignment were achieved with Class I canine and molar relationships.
Treatment was completed at the 18 months period after initiation, and profi le improvements with proper occlusion were obtained.     (Figures 7-8).
Mandibular arch length defi ciency was corrected within the mandibular dentition, and normal alignment was achieved without altering the arch form and width parameter.
The panoramic radiograph revealed good root parallelism and bone integration in the maxillary right canine area, as well as normal roots lengths of the maxillary right incisors (Figure 9).
The facial, skeletal, and dental changes were visible on post-treatment cephalometric radiograph with tracing and superimposition with pre-treatment situation (Figure 10-11).

Discussion
Treatment of non-growing patients with Class III malocclusion and with high lower anterior facial height represents signifi cant clinical challenge.
Recent systematic review revealed that quality of available evidences regarding effectiveness of using either orthognathic surgery or orthodontic approach for the treatment of Class III malocclusion remains low, while accessible data for comparison of above-mentioned interventions characterized with high level of heterogeneity [7]. One of the problems which limits the possibility to provide direct comparison between orthodontic and orthognathic treatment of Class III malocclusion is inability to provided true patients randomization considering ethical issues [7]. Also, analysis of available retrospective observational studies revealed that most of them were conducted on the Class III patients sample with minimal or no borderline condition regarding Class III malocclusion severity [7].
Set of case selection criteria has been previously proposed for camoufl aged orthodontic treatment of Class III, which includes straight or slight concave profi le, non-critically prominent retroclination of lower anterior teeth with the presence of adequate bone volume surrounding them, thick gingival biotype, suffi cient bone parameters behind molar area in lingual projection to the second molars [12].
Wits appraisal of −6.0 mm due to its relation with masseter muscle activity could be used as predictor for choosing orthognathic or camoufl aged approach for patients with Class III malocclusion [13]. Other study demonstrated that Holdaway angle greater than 10.3° and Wits appraisal greater than 5.8 mm could be use as determinants to choose camoufl aged orthodontic treatment of Class III malocclusion with a high chance to reach successful outcome [14].
In previous research Holdaway H angle was categorized as suffi cient discriminant with predictive power of 87.2% during process of choosing either orthognathic or camoufl aged orthodontic treatment for Class III malocclusion cases [15]. The same statement was provided in systematic review, where Wits and Holdaway H angle were classifi ed as the most reliable criteria for choosing correct treatment approach in cases of Class III malocclusion, while making decision between camoufl aged treatment and orthognathic surgery [16].
Zere et al. systematized cephalometric criteria that potentially may be used as predictors for the successful outcome of Class III orthodontic camoufl aged treatment [3]: • normal values of maxillomandibular differential and gonial angle [3]. Such predictors set may be expanded by the following parameters grouped within contemporary review: liner distance from condylion to A point and Gnathion; ratio of midfacial length to mandibular length; ratio of mandibular ramus height to mandibular body length [17]. Nevertheless, synthesis of the available evidences revealed no specifi c cephalometric cut-off levels that could be validated in full manner as markers to differentiate decision for using either orthognathic or camoufl aged orthodontic treatment for Class III malocclusion cases [18]. Meanwhile such parameters as ANB angle, Wits appraisal, overbite and overjet, gonial angle and presence of asymmetry have been previously used as discriminant factors for choosing one of the above-mentioned treatment approaches [18].
In 2022 artifi cial intelligence models trained with random forest and logistic regression demonstrated possibility of 90% accuracy regarding correct treatment decision making for Class III malocclusion patients taking into account parameters of overjet, Wits appraisal, lower incisor angulation, and Holdaway H angle as reliable predictors to argument need in providing surgical intervention [19].
Comparative studies of results obtained after Class III malocclusion patients have been treated either with camoufl age or orthognathic approach revealed following evidences [20]: • patients selected for camoufl age treatment are usually characterized with less severe initial dental and skeletal divergences; • orthognathic approach is associated with much more pronounced skeletal changes, while orthodontic approach is not, but surgical intervention also provokes valuable decompensation of lower incisors but not maxillary ones; • lip position changes during both orthognathic and camoufl aged treatment characterized with various individual-related pattern, but surgical intervention with greater chance will resolve it in more desirable outcome [20].
Burns et al. highlighted that sagittal jaw relationship (ANB angle) is not signifi cantly improving through realization of camoufl aged treatment used for Class III malocclusion in young adults, but despite that substantive dental and soft tissue changes may be observed if correct planning and treatment performance were provided [9]. Use of orthodontic camoufl age treatment for borderline cases of Class III malocclusion characterized with more pronounced effect of proclination for maxillary incisors and rectoclination on mandibular incision in comparison to orthodontic-orthognathic surgical treatment approach [6]. On the other hand, orthodonticorthognathic surgical treatment associated with protrusive effect regarding maxillary base and retrusive effect regarding mandibular base, meanwhile improvement within sagittal plane were associated with clockwise rotation effect of mandibular plane [6].
Contemporary review grouped potential contraindications for Class III camoufl aged orthodontic treatment, which includes: • severe cases of Class III with pronounced vertical divergences; • severe incisors crowding cases; • in cases where surgical interventions could provide better longterm results; • medically and periodontally compromised patients and mentally retarded persons; • patients with the personal need to achieve immediate results [17,21]. During camoufl aged treatment of a patient with a ''high angle'' Class III malocclusion, it is very important to avoid the fl are of anterior teeth in maxilla and the extrusion of maxillary posterior teeth with Class III elastics forces.
In presented clinical case report it was appropriate to avoid this kind of unfavorable reaction, an absolute anchorage source was used. On other hand there was a need to correct overbite and overjet, which was obtained by the distalization of entire lower dentition into its proper position with micro-implant anchorage. All of above-mentioned interventions contributed to the improvement in facial balance.
Due to the already available evidences, it may be also resumed that temporary anchorage devices signifi cantly improves outcomes of Class III camoufl aged orthodontic treatment, while helping to minimize need in extraction and optimizing treatment biomechanics [22]. Micro-implants help to enhance Class III orthodontic camoufl aged treatment by forming reliable anchorage for mandibular dentition distalization. There are two options of placing temporary anchorage devices during Class III camoufl aged treatment: either at mandibular retromolar or between 1st and 2nd molar area, or in maxilla in the interradicular area of 2nd premolar and 1st molar. The last strategy used to employ Class III elastics to anterior mandibular dentition, and greatly depends on patient's cooperation level [22].
Maxillary micro-implant anchorage combined with multiloop edgewise arch wire and modifi ed Class III elastics support tip of the mandibular molars distally without extrusion effect, while also could tip incisors lingually with controlled extrusion to provide suffi cient camoufl age effect for Class III skeletal malocclusion cases. Such treatment stage helps to avoid clockwise rotation of mandible and proclination effect for maxillary incisors [23]. Also approach of placing extra-alveolar micro-implant into the buccal shelf of mandible with putting nickel-titanium springs from temporary anchorage to the hooks of frontal segment at lower archwire was proposed as variant of camoufl aged treatment for Class III [22]. Venugopal A. et al. proposed micro-screw based "eight-point protocol" for achieving effi cient and stable results of Class III malocclusion treatment [24] Generally, TADs increase adaptability level of Class III malocclusion camoufl aged orthodontic treatment, which was approved in number of clinical trials, while also in recent systematic review [25,26,27].
On the other hand, even though considering evidences that micro-screws may be used for the effective treatment of Class III malocclusion, but no distinctive evidences has been found regarding is such approach improves treatment outcomes compare to the traditional intervention methods, such as disjunction and face mask [28].
Systematized advantages of using skeletal anchorage for Class III orthodontic treatment include following: minimized drawback of dental-based anchorage, possibility for greater maxillary Ukrainian Dental Journal, UDJ · 2 (2023) · 78-87 Hamid Rezaei, Svitlana Dovbenko Figure 12. Absolute anchorage may be applied in the molar area to prevent unwanted changes during camouflaged treatment of Class III malocclusion advancement, maximization of skeletal effect and minimization of clockwise mandible rotation, forming conditions for elastics wear during whole day with possibility to employ smaller traction forces, while minimizing risk of vertical changes in any craniofacial structures and enhancing a chance to achieve needed maxillary advancement in older patients compare to dental anchorage [28]. Stability of results achieved with orthodontic treatment of Class III malocclusion in great manner relies on fi nishing outcome: patients with better treatment-based dental and skeletal relations characterized with decreased risk of pathology relapse. Nevertheless, more pronounced maxillary incisor inclination before treatment associated with higher chance of initial malocclusion recurrence [29]. On the other hand, it should be remembered that more severe skeletal discrepancies of Class III malocclusion cases require more intensive camoufl aged approach for adequate compensation outcome [30]. Also, during Class III treatment outcome evaluation doctors should understand that improvement of profi le rather than simple occlusion changes could be interpreted as focus criteria during treatment effi ciency assessment [31].
Nowadays possibilities of 3D visualization, three-dimensional tracing and surface mapping functions help not only to compare pre-and post-treatment situation of Class III malocclusion cases, but alto to analyze it in dynamics during different treatment stages and verify specifi c changes within periodontium, soft tissues of face, bone structures and corpus variations of teeth, thus forming a complex pool of data which should be considered during treatment planning [32].

Conclusion
Camoufl aged orthodontic correction represents reliable treatment option for Class III malocclusion patients without remaining growth potential. Proper diagnostic decisions and indetail treatment planning should be provided to enhance a favorable coordination of changes within mandible and maxilla, optimize facial profi le improvements and occlusal harmonization. Micro-implants as skeletal anchorage devices represent reliable opportunity for camoufl aged orthodontic treatment of Class III malocclusion patients excluding the need in orthognathic surgery.

Confl ict of Interest
Author does not have any fi nancial or property interests that may concerning the materials presented in this article.

Funding
No funding was received to conduct this research.