It was fascinating to read the case report in the December issue (Maruo H, Maruo IT, Saga AY, Camargo ES, Filho OG, Tanaka OM. Orthodontic-prosthetic treatment of an adult with a severe Class III malocclusion. Am J Orthod Dentofacial Orthop 2010;138:820-8). This case report describes a Class III subdivision malocclusion in which, after crossbite correction, space was opened for first molar replacement by prosthetic means.

Considering the highly restored dentition and the patient’s age, the results were excellent. But from a clinician’s point of view, someone who bases treatment on the patient’s complaints and the best possible options, some serious points were missed.

Considering temporomandibular disorder (TMD) as the patient’s chief complaint, there was no mention of its possible etiology. Temporomandibular joint radiographs and magnetic resonance imaging scans would have been useful. It seems that perhaps the long-standing crossbite had led to this patien’s TMD. Before starting treatment, this should have been considered.

The authors selected an economically realistic, occlusally realistic, and restoratively realistic treatment option, but certain steps needed further clarification. First, what was the purpose of the anterior biteplane and how could it be placed in an anterior crossbite case? Second, the authors claimed that the anterior crossbite was corrected with aligning wires, but open-coil springs were used for protruding the anterior teeth. Why was this required? In the photograph, it appears that this step led to molar distalization, creating space for a molar. The mandibular third molars were absent. Thus, after prosthetic replacement, there were no antagonists for the maxillary third molars; this is evident in the panoramic radiograph and photographs. This could lead to extrusion of the maxillary third molars over time. A better option might have been to use Class III elastics, which could have solved most of the dental problems in the case. In that way, additional restorations in a heavily restored dentition could have been avoided. The maxillary third molars could have been placed in functional occlusion.

Although the results were excellent, in my opinion, the use of Class III elastics would have been a more economically realistic, occlusally realistic, and restoratively realistic treatment option. But, on the other hand, with their unconventional option, the authors achieved an excellent occlusion. The only thing that I am sure the authors thought of, but did not describe in detail in the article, was related to TMD.

I praise the authors for their interesting and thought-provoking article.