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Case Report
a r t i c l e i n f o a b s t r a c t
Article history: Treatment options of Class II malocclusion include extraoral headgears, functional appliances, and
Received 27 June 2012 conventional full-fixed appliances with intermaxillary elastics or combined with tooth extractions.
Received in revised form Various appliances have been used to distalize the maxillary molars. However, there are disadvantages,
23 July 2012
including laboratory time, patient compliance, and expenses. Despite the use of different components in
Accepted 26 July 2012
the design of the appliance to prevent the anchorage loss, flaring of the anterior teeth and increased
Available online 28 August 2012
overjet usually take place to a significant extent. This case report describes the use of the miniscrew
implantesupported sliding jigs distalization system (MISSJDS) for nonextraction treatment of a patient
Keywords:
Class II malocclusion
with a Class II malocclusion to distalize the maxillary molars in an invisible, noncompliant, and efficient
Miniscrew implants way, without mesial movement and proclination of the anterior teeth.
Molar distalization Ó 2012 World Federation of Orthodontists.
Fig. 1. The MISSJDS. (AeC) Placement of miniscrew implants in alveolar bone between the second premolars and the first molars in maxilla. (D) Intraoperative posterior-anterior x-
ray of implant placement. (E) Sliding jigs. (FeI) Application of Ni-Ti coil spring to sliding jigs.
fold (Fig. 2). Intraorally, he had Angle Class II molar relation on left 5. Correct the midline shift.
side and Class II tendency on right side with maxillary dentoal- 6. Create ideal overbite and overjet.
veolar protrusion (Figs. 2 and 3). He had mild mandibular crowding, 7. Ultimately establish a proper soft tissue profile.
an 8-mm overjet, 70% overbite, and mandibular midline shift
towards the left. Soft tissue analysis indicated that he had protru-
sive upper lip and retrusive lower lip (Table 1). 2.2. Treatment alternatives
The panoramic radiograph (Fig. 4) revealed no evidence of bony
pathology. All 32 teeth were present. After obtaining orthodontic The patient’s chief concern was the protruding maxillary
records, the patient was advised to have all 4 third molars extracted, incisors, and his parents wanted retraction of the maxillary
which was recommended by his oral surgeon; however, the patient anterior teeth. Initially, a treatment plan was discussed, involving
was not willing to have extraction. The lateral cephalometric extraoral headgear to be used for the maxillary molar distaliza-
radiograph (Fig. 4) and analysis (Table 1) demonstrated a skeletal tion and as a maximum anchorage device for the retraction of the
Class II malocclusion (A point, nasion, B point [ANB] ¼ 4 ) with anterior teeth, but the patient was more concerned about his
severe maxillary dentoalveolar protrusion and normally placed facial appearance. The patient and his parents rejected this
mandibular incisors (Mx1eNA ¼ 45 /12 mm; Md1eNA ¼ 26 / treatment option. A second treatment option was discussed,
5 mm; interincisal angle ¼ 104 ). The sella nasion (SN)-mandibular involving extraction of the maxillary first permanent premolars,
plane angle of 25 and Frankfort mandibular plane angle (FMA) of retraction and intrusion of the anterior teeth, and leveling and
17, indicated that the skeletal pattern was hypodivergent. A study alignment of the dental arches with conventional full-fixed
model analysis revealed a 6-mm space requirement in the maxillary appliances and possibly intermaxillary elastics. This option was
arch and 5-mm space requirement in the mandibular arch. also rejected by the patient’s parents, because they were against
extraction of healthy teeth for orthodontic purposes, and the
2.1. Treatment objectives patient was reluctant to wear intermaxillary elastics. A third
treatment option was discussed, involving the use of functional
Treatment objectives for this patient were as follows: appliance(s) to advance the mandible for the correction of molar
relation and to achieve normal overjet and overbite. The visual
1. Correct the maxillary dentoalveolar protrusion, because it was treatment objective (VTO) was evaluated and profile improve-
his chief complaint. ment was negative due to patient prominent chin button. For the
2. Improve the skeletal hypodivergent profile. treatment with this approach reduction genioplasty was advised
3. Establish Class I molar and canine relationship. after mandibular advancement with the functional appliance. But,
4. Relieve the crowding in mandibular arch. the patient and his parents were against any surgical treatment,
Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86 e81
so this plan was also declined. Thus, a final alternative involving 2.3. Treatment progress
distalization of the maxillary molars with the MISSJDS (Fig. 1) and
en-masse retraction and intrusion of the anterior teeth was dis- A 0.022-inch Roth edgewise appliance (Leone, Anaheim, CA) was
cussed. This treatment plan was selected by the patient and his used. Initially, the maxillary and mandibular arches were banded
parents. and bonded. A 0.016-inch nickel-titanium (Ni-Ti) archwire ligated
Table 1
Pretreatment and posttreatment lateral cephalometric analysis data
ANB, A point, nasion, B point; FMA, Frankfort mandibular plane angle; Gn, gnathion;
Go, gonial; IMPA, incisor to mandibular plane angle; NA, nasion point A; NB, nasion
point B; SN, sella nasion; SNA, sella nasion point A; SNB, sella nasion point B.
2.4. Treatment results and the dental midlines were aligned with facial midline. Posterior
occlusal relationships were improved to achieve Class I canine and
Dentoalveolar protrusion, which was the patient’s chief Class I molar relationships on both sides with good functional
complaint, was eliminated with the establishment of ideal overbite occlusion.
and overjet relationships. Correction of overbite improves the The photographs in Fig. 7 show a much-improved profile. The
condition of palatal mucosa. The midline deviation was corrected, upper lip has been retracted about 2 mm, with respect to the E lines,
and the lips are competent. The smile was improved, with less in the intercanine width in the maxilla and in the mandible,
amount of gingival exposure. The cephalometric analysis (Fig. 9 and whereas, the intermolar width increased by 1 mm in both the
Table 1) and superimposition (Fig. 10) revealed a significant amount maxilla and the mandible. The dental and periodontal health was
of vertical dental and skeletal changes during the treatment period, good and the panoramic radiograph (Fig. 9) examination indicated
which is seen on cephalometric superimpositions (Fig. 10 and satisfactory root paralleling except for the distal root angulation of
Table 1). The maxillary incisors were intruded 1.5 mm and retracted tooth 34 without any tissue loss.
4 mm in a bodily manner from the initial position. In the mandible,
the crowding of the lower incisors was resolved and the incisors
3. Discussion
were moved 1.5-mm labially. The maxillary molars were distalized
3 mm on the right and 3.5 mm on the left. There was 2-mm increase
Recently, many noncompliance appliances and approaches have
been presented to overcome the problem of compliance and
correction of Class II malocclusion efficiently [10e12]. However,
when noncompliance distalization appliances are used to correct
Class II malocclusion, three other problems are usually evident:
(1) anchorage loss of the anterior dental unit expressed as forward
movement and proclination of the anterior teeth, (2) distal tipping of
the molars during active maxillary molar distalization, and
(3) anchorage loss of the posterior dental unit also in the forward
direction that takes place after distalization during the subsequent
stages of anterior tooth retraction and final alignment of the dental
arches [13].
The miniscrew implants, which are temporary anchorage
devices, are now in widespread use by orthodontists. The temporary
implants used as skeletal anchors are alternatives that have provided
orthodontists with more options. So far, the clinical efficacy and
stability of implant anchorage miniscrews [14] and microscrews
[15,16] have been efficient skeletal anchorage devices that can
provide absolute anchorage for tooth movement, which cannot be
achieved by conventional methods. The miniscrew or microscrew
implants have many benefits; they are easy to place, are removable,
and are not expensive. The miniscrew implants are particularly small
enough to place in the inter-radicular bone or any area of the alveolar
bone depending on the need of tooth movement without discernible
damage to tooth roots, and orthodontic force application can begin
almost immediately after placement [17].
Noncompliance maxillary molar distalization with miniscrew
implants used as temporary stationary anchorage could be an
efficient treatment option for correcting Class II malocclusion. Our
treatment results support this new type of treatment biomechanics
because our patient, who had a Class II malocclusion and large
overjet and overbite, was successfully and efficiently treated; he
achieved a well-functioning Class I occlusion in 18 months without
Fig. 9. Panoramic and lateral cephalometric radiographs just before debonding. extractions and without the need for patient cooperation, except for
Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86 e85
Fig. 10. Superimposition of cephalometric tracings. (A) Registered on the sella nasion (SN) plane at S, black solid line for pretreatment and a red dotted line for posttreatment; (B) on
the palatal plane at A point, nasion, sella (ANS); and (C) on the mandibular plane.
maintaining oral hygiene. The miniscrew implants, initially used to the implants in place and prevent contact with the roots of the
distalize the maxillary molars and later used with conventional full- anterior teeth during or after their retraction. Thus, the side effects
fixed orthodontic appliances to retract and intrude the anterior of anchorage loss of the anterior dental unit during molar dis-
teeth, allowed the total orthodontic treatment to achieve a stable, talization and the posterior anchorage loss in terms of mesial molar
functional occlusion with good posterior intercuspation and bilat- movement during anterior tooth retraction with conventional dis-
eral Class I molar and canine relationship. In addition, the lips talization devices are eliminated with the use of the MISSJDS. If 4 to
competence and facial balance were improved. 5 mm of safety clearance is not present between the miniscrew
Nevertheless, a unique advantage of the MISSJDS is that the implants and the roots of adjacent teeth, another implant should be
same miniscrew implants can be used for temporary and stationary used between maxillary first and second molar to stabilize the
anchorage to support both molar distalization and anterior tooth molar after distalization and to provide indirect or direct anchorage
retraction, after a slight chair-side modification (Fig. 11). When for anterior teeth retraction.
using the MISSJDS, special attention should always be given to
positioning the implants far from the roots of the anterior teeth, not
4. Conclusions
only to present an initial clearance of 2 mm, which is needed to
prevent their contact with the roots of adjacent teeth if the
This case report demonstrates the efficient clinical use of the
implants move slightly during treatment [9], but also to present
miniscrew implants not only to distalize the maxillary molars but
a safe distance of 4 to 5 mm between the miniscrew implants and
also to retract the anterior teeth with full-fixed appliances,
the roots of the adjacent teeth, which is necessary for the retraction
providing an easy, noncompliance, nonextraction, and efficient
of the anterior teeth after molar distalization. This safety clearance,
approach for the complete orthodontic treatment of patients with
along with placement of the miniscrew implants, ensured that
Class II malocclusion.
there was enough bone, both quantitative and qualitative, to hold
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