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Correction o Class II deep overbite anddental and skeletal asymmetry with 2 types
o palatal miniscrewsCheol-Ho Paik,a Sug-Joon Ahn,b and Dong-Seok Nahmc
Seoul, Korea
From the Department o Orthodontics and Dental Research Institute, School o
Dentistry, Seoul National University, Seoul, Korea.aClinical assistant proessor.bAssistant proessor.cProessor.
Reprint requests to: Sug-Joon Ahn, Department o Orthodontics and Dental Re-
search Institute, School o Dentistry, Seoul National University, 28-22 Yunkeun-
Dong, Chongro-Ku, Seoul 110-768; Korea (ROK); e-mail: titoo@snu.ac.kr.
Submitted, September 2005; revised and accepted, February 2006.
0889-5406/$32.00
Copyright 2007 by the American Association o Orthodontists.
doi:10.1016/j.ajodo.2007;131:00
This case report describes the orthodontic treatment o a 31-year-old woman who had a Class II molar relationship,
anterior crowding, deep overbite, maxillary dental midline deviation, vertical maxillary asymmetry, and a hyperdivergent
acial pattern. The maxillary right frst premolar and the let second premolar were extracted asymmetrically to
correct the anterior crowding and the maxillary dental midline deviation. The maxillary molars were intruded with a
midpalatal miniscrew, which helped to correct the vertical molar asymmetry and close the mandibular plane. The
palatal miniscrew in the maxillary tuberosity was also used to provide anchorage reinorcement or retraction o
the anterior teeth. Ater orthodontic treatment, dental and acial esthetics were greatly improved by treatment o
anterior crowding and deep overbite, correction o the dental and skeletal asymmetry, and closure o the mandibularplane. At the 3-year ollow-up, most o the treatment results had been maintained. (Am J Orthod Dentoacial Orthop
2007;131:00)
The skeletal anchorage system has been intro-duced in orthodontics as a source o stable an-
chorage or orthodontic tooth movement.1-4 It
can help extend the feld o possible tooth movementby allowing more difcult movements to be achieved,
such as molar intrusion and distalization, which in-crease the anchorage burden. Recently, miniscrews or
mini-implants have been gaining in popularity. Their
advantages include decreased operative time, less po-tential morbidity, and a less invasive procedure be-
cause the size is small enough to allow placement inmost areas o the mouth where traditional implants and
onplants cannot be placed.2-5 The palate is a suitablearea or placement o miniscrews or several reasons,
including dense cortical bone, easy access, and lesssusceptibility to inammation.6 Miniscrews placed in
the palate have been used in various wayseg, or ad-
ditional anchorage during retraction o maxillary an-terior and posterior teeth, and intrusion o maxillary
posterior teeth.1,7,8
This patient had a Class II molar relationship anda deep overbite. In addition, she had anterior crowd-
ing, vertical maxillary asymmetry, a maxillary dental
midline deviation, and a hyperdivergent acial pattern.Asymmetric maxillary extraction with reinorced mini-
screw anchorage was planned to minimize the need orpatient compliance. Two types o palatal miniscrews
would be used to correct this malocclusion1 in the
midpalate and 1 in the right maxillary tuberosity. Themidpalatal miniscrew was placed to correct the verti-
cal molar discrepancy and intrude the maxillary molars.The miniscrew in the maxillary tuberosity was used
to provide absolute anchorage or retraction o the an-terior teeth. Good occlusion and acial esthetics were
achieved without the need or patient compliance, andthese results have been maintained or 3 years ater ac-
tive treatment.
DIAGNOSIS AND ETIOLOGY
A 31-year-old woman came or orthodontic evalu-
ation with a chie complaint o anterior crowding andprotrusive lips. She had a hyperdivergent acial pat-tern with a retrognathic mandible. Hyperactivity o
the mentalis muscle was observed with the lips sealed.
From the rontal view, the maxillary incisor displayat rest was 4 mm, and the maxillary dental midline
was 3 mm to the let o the acial midline (Fig 1). Thepatient had no apparent medical problems. Intraorally,
she demonstrated moderate crowding in the maxillaryand mandibular arches, a deep overbite (5.1 mm),
and a large overjet (6.4 mm). Her canine relationship
was Class II on both sides (Fig 2). The dental casts
CASE REPORT
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showed an almost ull-step Class II molar relationship
on the right and an end-on Class II relationship on thelet, which caused dental midline asymmetry in themaxillary arch due to orward drit o the maxillary
right posterior segment (Fig 3). Functional assess-
ment showed no marked discrepancy between centricocclusion and centric relation with no apparent signs
and symptoms o temporomandibular joint dysunc-tion. Oral hygiene and periodontal conditions were
relatively good.Panoramic radiographic assessment showed slight
root resorption o the maxillary let central incisor,
and the mandibular let third molar was tipped mesi-
ally and impacted horizontally (Fig 4). Lateral cepha-
lometric analysis (Fig 5, A; Table) showed a skeletalClass II relationship (ANB angle, 7.9; Wits appraisal,6.4 mm) due to a retrognathic mandible (SNB angle,
73.3; Pog to N perpendicular, 17.5 mm). The acial
pattern was hyperdivergent, as evidenced by a Frank-ort mandibular plane angle o 36.1. Although the
maxillary and mandibular incisors were normally po-sitioned, sot-tissue analysis showed protrusive upper
and lower lips to the Ricketts esthetic line due to theretrusive chin position.
Posteroanterior cephalometric analysis (Fig 5, B)
showed a chin point deviation to the let by 3.0 mm
Fig 1. Pretreatment acial photographs.
Fig 2. Pretreatment intraoral photographs.
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rom the skeletal midline caused by vertical maxillaryasymmetry. The maxillary right frst molar was extrud-
ed 2.5 mm more than the let. The maxillary dental mid-line was deviated to the let, leading to a 3.0-mm dental
midline discrepancy. The mandibular midline was coin-
cident with the acial midline.
TREATMENT OBJECTIVES
The main treatment objectives were to normalizethe overjet and overbite relationships and to improve
the acial profle. For these goals, the maxillary incisors
would be retracted and intruded, and the midline devia-tion corrected. During retraction, the maxillary incisor
Fig 3. Pretreatment study models.
Fig 4. Pretreatment radiographs.
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angulation would be maintained, and the anterior maxil-lary teeth would be retracted bodily. The bilateral Class
II canine relationship would need correction along withthe dental midline discrepancy.
An improved posterior occlusal relationship wouldalso be needed to obtain maximal intercuspation o theposterior teeth. Correction o the vertical discrepancy in
the maxillary molars would help to treat the acial asym-metry and improve the posterior occlusal relationships.
As a result, retraction o the maxillary and mandibu-lar incisors and bite opening would improve lip protru-
sion and reduce mentalis hyperactivity and lead to better
acial esthetics.
TREATMENT ALTERNATIVES
The patients chie complaint was anterior crowd-
ing and lip protrusion. Because o the skeletal discrep-ancy, the frst alternative was orthognathic surgery. In
this option, to resolve anterior crowding, the 2 maxil-
lary second premolars and the 2 mandibular frst pre-molars would be extracted and retracted with moderate
anchorage. Canting correction o the maxillary verticaldiscrepancy would be perormed to correct acial asym-
metry and improve the posterior occlusal relationships.Total maxillary impaction, which induces mandibular
autorotation and reduces tooth display, and concurrent
mandibular advancement surgery could be planned toimprove the acial profle. Advancement genioplasty
would reduce the long lower acial height and move thechin orward. However, the patient rejected this option
because o the extensive surgeries.A nonsurgical approach with 2 alternatives was
presented to the patient. The frst option was to extract2 maxillary frst premolars and 2 mandibular secondpremolars to achieve bilateral Class I molar and ca-
nine relationships with ideal overbite and overjet. Thesecond option was to extract the maxillary right frst
premolar and the maxillary let second premolar anduse asymmetric mechanics with palatal miniscrews to
correct the dental midline deviation and the vertical
maxillary asymmetry. The result o the second optionwould be a bilateral Class I canine relationship and a
Class II molar relationship.The second option was selected because the asym-
metric extraction o the maxillary premolars would helpto provide space to resolve the dental midline discrepancy
and the incisor crowding. The palatal miniscrews would
be helpul or correcting the vertical molar discrepancyand controlling the anteroposterior molar position. This
plan, with palatal miniscrews and asymmetrical extrac-tion, could minimize the need or patient compliance.
TREATMENT PROGRESS
The maxillary right frst and let second premolars
and the horizontally impacted mandibular let third mo-lar were extracted. The maxillary and mandibular frst
Fig 5. Pretreatment lateral and posteroanterior cephalometric tracings.
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and second molars were banded, and fxed preadjustededgewise appliances with .022-in slots were placed in
both arches. Initially, 0.014-in nickel-titanium leveling
archwires were placed.A transpalatal arch was attached between the maxil-
lary frst molars during initial leveling. A drill-ree mini-
screw (length, 6.0 mm; diameter, 1.6 mm; OSAS, Seoul,Korea) was placed in the midpalatal area between the
maxillary frst and second molars under local anesthe-
sia (Fig 6,A). Two weeks later, an elastic module (orce,150 g) was connected rom the miniscrew to the hook o
the transpalatal arch to intrude the maxillary molar and
Fig 6. Palatal miniscrews: A, in midpalate; B and C, in maxillary tuberosity.
Table. Summary o cephalometric analysis
Measurement Korean norm Before treatment After treatment
3 years after
treatment
Vertical skeletal relationships
FMA (o
) 28.8 36.1 32.7 32.8SN to mandibular plane angle (o) 35.3 44.7 42.7 42.8
Gonial angle (Ar-Go-Me) (o) 122.2 121.3 121.8 121.7
Total anterior acial height (N-Me) (mm) 130.3 132.2 130.7 130.2
Total posterior acial height (S-Go) (mm) 82.9 79.6 80.4 79.7
Total anterior acial height/total posterior acial height (%) 63.6 60.2 61.5 61.2
Maxillomandibular relationships
SNA angle (o) 81.1 81.2 79.1 79.4
SNB angle (o) 78.0 73.3 74.5 74.3
A to N perpendicular (mm) 0.5 0.1 2.5 2.0
Pog to N perpendicular (mm) 4.5 17.5 15.2 15.2
Facial convexity (N-A-Pog) (o) 7.6 17.4 11.1 11.4
ANB angle (o) 3.1 7.9 4.6 5.1
Wits appraisal (mm) 1.5 6.4 1.8 1.1
Dental relationships
Maxillary incisor to Frankort horizontal plane (o) 111.1 110.0 111.1 108.2
Interincisal angle (o) 124.1 121.4 120.4 122.7
Mandibular incisor to mandibular plane angle (o) 96.3 92.5 94.8 95.4
Overbite (mm) 3.1 5.1 2.9 3.1
Overjet (mm) 3.0 6.4 3.4 3.0
Sot-tissue relationships
Ricketts E-line to upper lip (mm) 0.0 2.1 1.6 2.3
Ricketts E-line to lower lip (mm) 0.1 4.9 1.7 1.7
A B C
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maintain maximum anchorage conditions in the maxillaryright quadrant.
Ater correction o the vertical molar discrepancy,both the let and right molars were intruded to close
the mandibular plane; this would help to improve thepatients acial profle. During this stage, we needed
intrusion o both the maxillary and mandibular inci-sors, because intrusion o the maxillary molars would
induce premature contacts o the incisors. An exagger-
ated curve o Spee was applied to the maxillary archor intrusion o the maxillary incisors without extrusion
o molars. Class III elastics and an exaggerated reversecurve o Spee were also applied to the mandibular arch
to intrude the mandibular incisors without proclination.Ater the maxillary molars were intruded, the midpala-
tal miniscrew was removed to prevent unnecessary sot-tissue irritation. At the completion o vertical control,
a high-pull headgear was used to maintain the verticalmolar position at night.
A .019 .025-in stainless steel archwire with an-
terior hooks was placed to retract the maxillary anteri-or segment. At this time, a second miniscrew (length,
Fig 8. Posttreatment intraoral photographs.
Fig 7. Posttreatment acial photographs.
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6.0 mm; diameter, 1.6 mm; OSAS) was placed in the
palate around the right maxillary tuberosity to providemaximum anchorage in the maxillary right quadrant
(Fig 6,B). An elastic module (orce, 150 g) was con-
nected rom the miniscrew to the right hook o the
transpalatal arch to help correct the dental midlinediscrepancy and the posterior occlusal relationships
in this area. The retraction orce was applied rom the
Fig 9. Posttreatment study models.
Fig 10. Posttreatment radiographs.
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hook to the maxillary second molar on the right side
and to the maxillary frst molar on the let side orasymmetric retraction.
Brackets, bands, and the palatal miniscrew were re-moved ater 26 months o active treatment. Twist wire
fxed retainers (.0215 in) were attached to the lingualsuraces o the anterior segments o both arches imme-
diately ater debonding. A circumerential maxillary re-
tainer was also placed the day ater debonding .
TREATMENT RESULTS
The original treatment objectives were all achieved.
The patient developed an attractive and confdent smile.Posttreatment evaluation showed avorable dental and
acial changes (Figs 7 and 8). The acial profle and lip
support were improved, and the mentalis hyperactivity
was reduced. Incisor exposure during posed smiling wasimproved. Intraorally, both arches were well alignedand coordinated, the maxillary midline deviation was
corrected, and normal overbite and overjet relationshipswere achieved. The posterior occlusion had good over-
all intercuspation and was reasonably well settled in abilateral Class II molar relationship (Figs 8 and 9).
The posttreatment panoramic radiograph showed
good overall root parallelism (Fig 10). The let centralincisor and the other incisors showed no signs o urther
root resorption, despite the considerable amount o intru-
sion o the maxillary incisors. The posttreatment lateral
cephalometric radiograph and the superimposed tracingshowed that the anterior acial height and the Frankort
mandibular plane angle had decreased, reecting auto-rotation o the mandible by intrusion o the maxillary
molars (Figs 10 and 11, Table). The maxillary incisorswere retracted bodily and intruded, and the maxillary
posterior teeth were intruded and moved anteriorly. The
mandibular incisors were slightly retracted with intru-sion, and the mandibular posterior teeth were upright-
ed. There was considerable remodeling o subspinalethrough retraction o the maxillary incisors. There was
also general improvement in the sot-tissue relationshipand in nose, lip, and chin balance. Lip protrusion was
reduced, and the nasolabial angle was improved.
The posttreatment posteroanterior cephalometric
radiograph showed that the vertical discrepancy o themaxillary molars was corrected along with the mandib-ular asymmetry.
RETENTION EVALUATION
Ater debonding, the patient had regular ollow-upcare; she wore the circumerential maxillary retainer
24 hours a day or the frst year, ollowed by another
next year o nighttime wear, and every other night orthe third year. The lingual retainers will be kept semi-
permanently to enhance long-term stability. No apparent
Fig 11. Cephalometric superimposition o pretreatment and posttreatment stages.
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changes were noted in the occlusion during this period.
The occlusal settling improved, and the 3-year posttreat-ment stability was excellent (Figs 12 and 13). Comparison
o the posttreatment and 3-year retention cephalometrictracings showed negligible dental and skeletal changes
in the maxilla and the mandible (Fig 14, Table). Only aslight retroclination o the maxillary incisors and a slight
proclination o the mandibular incisors were observed.
DISCUSSION
Orthodontic miniscrews are being used increasinglyor absolute anchorage.1-5 A site suitable or orthodontic
miniscrews is the midpalate, because o its easy access
with little danger o damaging anatomical structures ex-
cept the incisive canal.6
The midpalate consists o densecortical bone, which contributes to the retention o im-
plants7 and miniscrews.9 Several studies reported thatthe thick dense cortical bone o the midpalate (average,
5.0-7.0 mm) can withstand a 6-mm vertical depth o theminiscrew, i the incisive canal is avoided and the midpal-
atal suture is closed.10-12 Nevertheless, the miniscrew canpenetrate the nasal oor in some patients, because bone
thickness around the midpalate has great individual varia-
tion.10,11 However, previous studies showed that hard andsot tissues around the penetrating implants were covered
with connective tissue and coated with respiratory mu-
Fig 12. Postretention acial photographs.
Fig 13. Postretention intraoral photographs.
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cosa,13 and did not show signs o adverse tissue reactions
on the radiographic views.14 In our patient, the frst mini-screw was placed in the midpalate, away rom the incisive
canal. The size o the miniscrew was 1.6 mm in diameterand 6.0 mm in length; this could provide adequate bone
support or the continuous intrusive orce without ailureo the miniscrew and without adverse side eects.
The second miniscrew was placed into the upper part
o the palate around the maxillary tuberosity. The maxil-
lary tuberosity region is becoming increasingly involvedas part o comprehensive dental implant treatment plan-ning.15,16 The placement o implants in this region is oten
difcult because o insufcient bone volume due to themaxillary sinus and the relatively poor bone quality when
compared with the anterior segment o the maxilla.17 For
dental implants, occlusal orces in the posterior region aregreater than those exerted in the anterior region, and the
bone quality o the maxillary tuberosity is not sufcientto withstand these orces. However, the orthodontic load
on the miniscrew was much less than the occlusal orce,which will not cause excessive stress on the miniscrew.
In this patient, we confrmed that the sinus was not inthe insertion area (Figs 4 and 6, C); the sinus is the main
reason or insufcient bone volume. Thereore, the mini-
screw provided enough bony support to resist the 150 go orthodontic load despite its small size.
Dental midline discrepancies are difcult to correct,particularly in adults with Class II malocclusion. Many
approaches can be used to achieve an acceptable mo-lar relationship, including asymmetric headgear18 and
asymmetric interarch elastic wear.19 These approachesneed excellent patient compliance. In addition, attempt-
ing to achieve midline coordination with asymmetric
elastic wear, such as a combination o Class II and an-terior diagonal elastics, can be associated with undesir-
able side eects created by the elastics, such as extru-sion o the molar, increase in vertical dimension, and
concurrent clockwise rotation o the mandible.20
One approach or managing dental asymmetriesis to extract teeth asymmetrically; this will reduce the
dependency on patient compliance or elastic wear orextraoral appliances, and might even shorten treatment
time. In addition, asymmetric extractions help to simpli-y the treatment plan when dealing with buccal segment
asymmetries at the same time. This patient had a dentalmidline deviation combined with buccal segment asym-
metry (ull-step Class II on the right and end-on Class II
on the let), which needed asymmetric dental extractionsto achieve the desired treatment results. In this patient,
Class I closure mechanics were applied to the let max-
illary molar with the end-on Class II relationship; thishelped the let molar to ft into a Class II relationship.However, additional anchorage was required to correct
the dental midline deviation and the anterior crowding
on the right side, because the right molar was already ina ull-step Class II relationship. The palatal miniscrew
in the maxillary tuberosity area prevented anchorageloss o the maxillary molar on the right side.
Correction o a deep bite is difcult in adults, andthe results can be unstable. Bite correction by extrusion
o posterior teeth is unstable in adult patients.21 Further-
more, archwire systems or incisor intrusion, such as the
utility arch,22
can create a reactive orce that elongatesthe molars, and this can be detrimental to the acial pro-fle by counterclockwise rotation o the mandible, par-
ticularly in an adult with a hyperdivergent acial pattern.This means that additional anchorage is needed to intrude
the incisors. High-pull headgear is used or preparation
o molar anchorage, but it requires excellent patient co-operation. The miniscrew can be an excellent alternative
in this situation. In this patient, the maxillary incisorswere intruded by incorporating an exaggerated curve o
Spee into the maxillary archwire without extrusion o themaxillary molar with midpalatal miniscrew anchorage.
Fig 14. Cephalometric superimposition between post-treatment and postretention stages.
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In addition, the net intrusion o the maxillary molars in-duced counterclockwise rotation o the mandibular plane,
with concurrent improvement o the acial profle. As a
result, we obtained skeletal eects resembling those o aLeFort I total maxillary impaction, which we originally
planned to correct this patients skeletal discrepancy.Apical root resorption is an undesirable and irre-
versible side eect o orthodontic therapy. Intrusion isa dangerous tooth movement, because axial orces are
concentrated in a relatively small area near the apex dueto the conical shape o the root.23 Extremely light orces
should be used to produce appropriate pressure in the
periodontal ligament.23 Many studies have reported theoptimum orce or intrusion. Burstone24 suggested 20 g
o orce or intrusion o anterior teeth, and Gianelly andGoldman25 recommended 15 to 50 g o orce or small
teeth. For intruding molars, rom 50 to 500 g per tooth
has been recommended, which is over 3 times greaterthan orces applied on anterior teeth.3,26,27 In this patient,
the maxillary anterior and posterior teeth were intrudedthrough various archwire systems and palatal miniscrews.
An archwire system with an exaggerated curve o Speewas used with midpalatal miniscrew anchorage or intru-
sion o the maxillary anterior teeth. This archwires werechanged slowly rom light round to heavy rectangular
wire. In the maxillary posterior teeth, 150 g o light orce
was used to intrude the maxillary molars. As a result, op-timal intrusion could be achieved without apparent root
resorption during the active treatment period.
CONCLUSIONS
Asymmetrical maxillary extraction and 2 types opalatal miniscrews were used to correct a Class II den-
tal relationship, anterior crowding with deep overbite,and maxillary dental and skeletal asymmetry without
patient compliance. This case report demonstrates thatthe palatal miniscrew anchorage method can provide the
additional orthodontic anchorage needed to intrude and
retract maxillary incisors and molars.
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