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Nonextraction treatment with temporary skeletal anchorage devices to correct a Class II Division 2 malocclusion with excessive gingival display Makoto Nishimura, a Minayo Sannohe, b Hiroshi Nagasaka, c Kaoru Igarashi, d and Junji Sugawara e Sendai and Saitama, Japan, and Farmington, Conn The patient was a 22-year-old Japanese woman who complained of a gummy smile. She had several other or- thodontic problems, including crowding of the maxillary anterior teeth, retroclination of the maxillary central in- cisors, excessive maxillary incisor display, a deep overbite, Class II dental relationships, a Class II prole, and a long face. Two options for the correction of these problems were proposed. The rst option was to extract the maxillary rst premolars to correct the Class II relationship and implant a miniscrew to correct the gingival display; the second option was to place 2 miniplates for distalization of the maxillary molars and a miniscrew to correct the gingival smile without premolar extractions. The patient chose the second option. After placing a preadjusted bracketed system, 2 miniplates were placed in the zygomatic buttresses bilaterally with monocort- ical screws, and 1 miniscrew was xed between the root apices of the maxillary central incisors. Distalization and intrusion of the maxillary molars and intrusion of the maxillary incisors were simultaneously started with those temporary skeletal anchorage devices functioning as absolute orthodontic anchors. The total treatment period was approximately 22 months. Her orthodontic problems were corrected. According to the cephalometric eval- uation, the entire maxillary dentition was signicantly distalized, and her maxillary incisors were successfully intruded, with the mandible showing a slight counterclockwise rotation. Thanks to the temporary anchorage de- vices combined with miniplates and a miniscrew, we were able to predictably achieve her treatment goals without premolar extractions, orthognathic surgery, and the need for patient compliance. (Am J Orthod Dentofacial Orthop 2014;145:85-94) T he prevalence of Angle Class II Division 2 maloc- clusion is relatively low in comparison with other malocclusions. 1-3 This malocclusion is generally characterized by retroclination of the maxillary incisors, a deepbite, and an obtuse interincisal angle. 4 In the treatment of a Class II Division 2 malocclusion, the improvement of a deepbite with a gummy smile is a challenging treatment objective. Conventional ortho- dontic methods, such as an intrusive arch, have been used to reduce overbite, often resulting in undesirable extrusion and aring of the posterior teeth. 5 The clock- wise rotation of the mandible caused by the extrusion of the posterior teeth worsens the Class II convex prole in many patients and also leads to an increase in the inci- dence of relapse for adults. 6-10 Extraoral appliances to reduce overbite, such as the J-hook, are effective in controlling the anchorage, but it is difcult to predict the nal result in uncooperative patients. 11 There is a clear need for a procedure for patients with deepbite and excessive gingival display resulting a gummy smile that effectively intrudes the maxillary incisors without undesirable side effects and without their cooperation. The successful use of temporary skeletal anchorage devices (TSADs) as absolute anchorage to reduce over- bite in nongrowing patients has been reported. 12,13 However, no case report has detailed the simultaneous intrusion of the anterior teeth to correct a gummy smile and distalization of the maxillary posterior teeth to correct molar relationships. a Assistant professor, Division of Oral Dysfunction Science, Graduate School of Dentistry, Tohoku University, Sendai, Japan. b Private practice, Saitama, Japan. c Lecturer, Division of Maxillofacial Surgery, Graduate School of Dentistry, To- hoku University, Sendai, Japan. d Professor, Division of Oral Dysfunction Science, Graduate School of Dentistry, Tohoku University, Sendai, Japan. e Visiting clinical professor, Division of Orthodontics, Department of Craniofacial Science, School of Dental Medicine, University of Connecticut, Farmington, Conn; chief orthodontist, SAS Orthodontic Centre, Ichiban-cho Dental Ofce, Sendai, Japan. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest, and none were reported. Address correspondence to: Makoto Nishimura, Division of Oral Dysfunction Sci- ence, Department of Oral Health and Development Sciences, Graduate School of Dentistry, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan; e-mail, [email protected]. Submitted, January 2012; revised and accepted, June 2012. 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.06.022 85 CASE REPORT
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Page 1: Nonextraction treatment with temporary skeletal anchorage ... · intrusion of the maxillary molars and intrusion of the maxillary incisors were simultaneously started with those temporary

CASE REPORT

Nonextraction treatment with temporary skeletalanchorage devices to correct a Class II Division 2malocclusion with excessive gingival display

Makoto Nishimura,a Minayo Sannohe,b Hiroshi Nagasaka,c Kaoru Igarashi,d and Junji Sugawarae

Sendai and Saitama, Japan, and Farmington, Conn

aAssisDentibPrivacLectuhokudProfeTohokeVisitiScienConnSendaAll auPotenAddreence,DentiJapanSubm0889-Copyrhttp:/

The patient was a 22-year-old Japanese woman who complained of a gummy smile. She had several other or-thodontic problems, including crowding of the maxillary anterior teeth, retroclination of the maxillary central in-cisors, excessive maxillary incisor display, a deep overbite, Class II dental relationships, a Class II profile,and a long face. Two options for the correction of these problems were proposed. The first option was to extractthe maxillary first premolars to correct the Class II relationship and implant a miniscrew to correct the gingivaldisplay; the second option was to place 2 miniplates for distalization of the maxillary molars and a miniscrewto correct the gingival smile without premolar extractions. The patient chose the second option. After placinga preadjusted bracketed system, 2 miniplates were placed in the zygomatic buttresses bilaterally with monocort-ical screws, and 1miniscrewwas fixed between the root apices of themaxillary central incisors. Distalization andintrusion of the maxillary molars and intrusion of the maxillary incisors were simultaneously started with thosetemporary skeletal anchorage devices functioning as absolute orthodontic anchors. The total treatment periodwas approximately 22 months. Her orthodontic problems were corrected. According to the cephalometric eval-uation, the entire maxillary dentition was significantly distalized, and her maxillary incisors were successfullyintruded, with the mandible showing a slight counterclockwise rotation. Thanks to the temporary anchorage de-vices combinedwithminiplates and aminiscrew, wewere able to predictably achieve her treatment goals withoutpremolar extractions, orthognathic surgery, and the need for patient compliance. (Am J Orthod DentofacialOrthop 2014;145:85-94)

The prevalence of Angle Class II Division 2 maloc-clusion is relatively low in comparison with othermalocclusions.1-3 This malocclusion is generally

characterized by retroclination of the maxillaryincisors, a deepbite, and an obtuse interincisal angle.4

In the treatment of a Class II Division 2 malocclusion,

tant professor, Division of Oral Dysfunction Science, Graduate School ofstry, Tohoku University, Sendai, Japan.te practice, Saitama, Japan.rer, Division of Maxillofacial Surgery, Graduate School of Dentistry, To-University, Sendai, Japan.ssor, Division of Oral Dysfunction Science, Graduate School of Dentistry,u University, Sendai, Japan.ng clinical professor, Division of Orthodontics, Department of Craniofacialce, School of Dental Medicine, University of Connecticut, Farmington,; chief orthodontist, SAS Orthodontic Centre, Ichiban-cho Dental Office,i, Japan.thors have completed and submitted the ICMJE Form for Disclosure oftial Conflicts of Interest, and none were reported.ss correspondence to: Makoto Nishimura, Division of Oral Dysfunction Sci-Department of Oral Health and Development Sciences, Graduate School ofstry, Tohoku University, 4-1 Seiryo-machi, Aoba-ku, Sendai 980-8575,; e-mail, [email protected], January 2012; revised and accepted, June 2012.5406/$36.00ight � 2014 by the American Association of Orthodontists./dx.doi.org/10.1016/j.ajodo.2012.06.022

the improvement of a deepbite with a gummy smile isa challenging treatment objective. Conventional ortho-dontic methods, such as an intrusive arch, have beenused to reduce overbite, often resulting in undesirableextrusion and flaring of the posterior teeth.5 The clock-wise rotation of the mandible caused by the extrusion ofthe posterior teeth worsens the Class II convex profile inmany patients and also leads to an increase in the inci-dence of relapse for adults.6-10 Extraoral appliances toreduce overbite, such as the J-hook, are effective incontrolling the anchorage, but it is difficult to predictthe final result in uncooperative patients.11 There is aclear need for a procedure for patients with deepbiteand excessive gingival display resulting a gummy smilethat effectively intrudes the maxillary incisors withoutundesirable side effects and without their cooperation.

The successful use of temporary skeletal anchoragedevices (TSADs) as absolute anchorage to reduce over-bite in nongrowing patients has been reported.12,13

However, no case report has detailed the simultaneousintrusion of the anterior teeth to correct a gummysmile and distalization of the maxillary posterior teethto correct molar relationships.

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Fig 1. Pretreatment facial and intraoral photographs.

86 Nishimura et al

In this case report, we present the nonextractiontreatment of an adult with a Class II Division 2 malocclu-sion whose deep overbite and gummy smile were pre-dictably corrected using TSADs combined withminiplates and a miniscrew on the basis of a goal-oriented approach.

DIAGNOSIS AND ETIOLOGY

The patient, a 22-year-old Japanese woman, had aconvex profile, a Class II malocclusion, and excessivedisplay of her maxillary incisors (Fig 1). Her chiefcomplaint was a gummy smile. A short upper lip and hy-peractivity of the elevator muscles of the upper lip werefound in the clinical examination and are clearly shownin her pretreatment smiling photograph. Intraorally, shehad Class II molar relationships bilaterally, a deep over-bite, retroclination of the maxillary incisors, a highcanine on the left hand side, and anterior crowding inthe maxilla (Fig 2).

The initial lateral cephalometric radiograph wastaken in natural head position with relaxed lip posture

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and at centric relation (Fig 3). The cephalometric tem-plate analysis (Fig 4) and the cephalometric measure-ments (Table) clearly indicated that she had a skeletalClass II profile, retroclination of the maxillary central in-cisors, and excessive eruption of the maxillary incisors.The panoramic radiograph showed her bilateral mandib-ular third molars. The level of alveolar bone crest waswithin the normal range, and she had healthy peri-odontal tissues (Fig 5).

TREATMENT OBJECTIVES

The principal treatment objectives were to achieveoptimal overjet and overbite, improve her gummy smile,and establish Class I canine and molar relationships.Figure 6 shows her treatment goal on the basis of thecephalometric prediction. According to her treatmentgoal, the maxillary central incisors and first molars neededto be intruded by 4.0 and 1.0 mm, respectively. The intru-sion of the entire maxillary dentition was expected toinduce a counterclockwise rotation of themandible, in ef-fect improving her Class II profile and significantly

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Fig 2. Pretreatment dental models.

Fig 3. Pretreatment cephalometric radiograph.

Nishimura et al 87

reducing her large interlabial gap. In addition, a 4.0-mmaverage bilateral distalization of the maxillary molars wasneeded to correct her Class II dentition.

American Journal of Orthodontics and Dentofacial Orthoped

TREATMENT ALTERNATIVES

The development of TSADs has made it possible tocorrect a gummy smile successfully without surgery.Orthognathic surgery is no longer the first option forthe correction of a gummy smile. The patient was given2 nonsurgical alternatives: the first option was toextract the maxillary first premolars for Class II correc-tion and implant a miniscrew for gummy simile correc-tion, and the second option was to place 2 miniplatesfor distalization of the maxillary molars and a mini-screw for gummy smile correction without premolarextractions.

Since she was reluctant to have her 2 maxillary pre-molars extracted, she decided on the second option.

TREATMENT PROGRESS

Before starting the orthodontic treatment, the bilat-eral mandibular third molars were extracted. Subse-quently, 0.022-in preadjusted brackets were bonded atthe maxillary posterior teeth, nickel-titanium archwireswere engaged for leveling and aligning segmentally,and titaniumminiplates (Dentsply Sankin, Tokyo, Japan)were implanted at the zygomatic buttresses bilaterallyunder local anesthesia by an oral surgeon. A 0.032 30.032-in transpalatal arch was placed to prevent buccalexpansion of the first premolars after distalization of themaxillary posterior teeth and buccal flaring of the molarsduring intrusion of the maxillary molars.

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Fig 4. Craniofacial drawing standards analysis.

Table. Cephalometric analysis

Pretreatment PosttreatmentRetention

2 y NormSNA (�) 76 75 75 82SNB (�) 69 69 69 80.5ANB (�) 7 6 6 1.5AB to occlusalplane (mm)

4 3 4 -

U1 to SN (�) 77.5 94 90.5 107.5SN-OP (�) 27 25 24 16FMA (�) 35.5 35 35 29IMPA (�) 91 96 97 96.5FMIA (�) 53.5 49 47 54.5Interincisal angle (�) 145.5 124 126 127Upper lip (mm) 0 �1 �1 �1Lower lip (mm) 1 0 �0.5 0

Fig 5. Pretreatment panoramic radiograph.

Fig 6. Treatment goal.

88 Nishimura et al

Three weeks after the implantation surgery, distaliza-tion of the maxillary posterior segments was started withelastic chain modules. The magnitude of orthodonticforce for distalization was 250 g per side. During

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distalization of the maxillary posterior segments, thebuccal archwires were ligated to the transpalatal archat the maxillary first premolar to prevent expansion ofthe first premolar (Figs 7, A, 8, A, and 9, A).

Four months later, brackets were bonded at themaxillary anterior dentition, and a miniscrew was fixedbetween the root apices of the maxillary central incisors.Thereafter, leveling and aligning of the entire maxillarydentition and intrusion of the maxillary incisors werestarted by applying an elastic thread tied from thehead of the miniscrew to the archwire between themaxillary central incisors (Figs 7, B; and 8, B). Then,after engaging a rigid rectangular wire (0.0175 30.025-in stainless steel), distalization of the entiremaxillary dentition was started. Orthodontic force wasdelivered from the miniplates to the power arms thatwere placed between the maxillary canines and first pre-molars (Figs 7, C, 8, C, and 9, B).

Ten months later, brackets were bonded on the entiremandibular dentition, and leveling and aligning wereinitiated with a nickel-titanium archwire. The intrusionof the entire maxillary arch started with the application

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Fig 7. A-F, Treatment progress intraoral photographs, frontal view.

Fig 8. A-F, Treatment progress intraoral photographs, lateral view.

Fig 9. A-C, TSAD mechanics for distalization of molars and intrusion of incisors and maxillarydentition.

Nishimura et al 89

of specific mechanics. The maxillary incisors wereintruded using a miniscrew, and the canines and premo-lars were intruded by intrusion cantilevers. Those levers

American Journal of Orthodontics and Dentofacial Orthoped

were inserted into the buccal tubes bonded on thehead portion of the miniplates. In addition, anotherintrusive force was bilaterally applied with elastic threads

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Fig 10. Posttreatment facial and intraoral photographs.

Fig 11. Posttreatment dental models.

90 Nishimura et al

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Fig 12. Posttreatment cephalometric radiograph.

Fig 13. Posttreatment cephalometric superimposition.

Fig 14. Posttreatment panoramic radiograph.

Nishimura et al 91

from the miniplates to the maxillary first molars at thesame time (Figs 7, D, 8, D, and 9, C).

After intrusion of the maxillary dentition, distaliza-tion of the entire maxillary dentition was carried out to

American Journal of Orthodontics and Dentofacial Orthoped

correct the molar relationships and overjet (Figs 7, E,and 8, E). Through the finishing and detailing stage,a functional occlusion with proper anterior guidanceand rigid posterior support was established (Figs 7, F,and 8, F). Since the clinical crown length of themaxillary incisors was reduced by the intrusion,electrical cautery was used to modify the gingivalmargins of the maxillary incisors once the intrusionwas completed.

After 22 months of active orthodontic treatment, themultibracketed system and all the TSADs were removed.Immediately after debonding, a wraparound type ofretainer in the maxillary dentition and a lingual bondedretainer from canine to canine in the mandibular denti-tion were placed.

TREATMENT RESULTS

Thanks to the application of the 2 types of TSADs, thepatient's orthodontic problems dramatically improved.She obtained a balanced profile, and her gummy smileand deepbite were dramatically corrected. The canineand molar relationships were normalized from Class IIto Class I. A functional occlusion with stable posteriorsupport and proper anterior guidance was established(Figs 10 and 11).

The cephalometric superimposition before and aftertreatment showed that her treatment goals were predict-ably achieved (Figs 12 and 13). Particularly worthy ofnote is the accuracy of the results of the maxillary inci-sors and molar positions: these were almost exactly thesame as the treatment goals. The maxillary first molarswere intruded about 1.5 mm and distalized by 4.0mm. The maxillary central incisors were intruded by3.5 mm. The amount of counterclockwise rotation ofthe mandible was less than predicted. The panoramicradiograph taken at debonding showed that her maxil-lary and mandibular dentitions had proper root paral-lelism (Fig 14). A stable occlusion and a balancedprofile have been maintained during the 2-year follow-up period (Figs 15 and 16).

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Fig 15. Two-year posttreatment facial and intraoral photographs.

Fig 16. Two-year posttreatment panoramic radiograph.

92 Nishimura et al

DISCUSSION

A gummy smile is the result of a combination of fac-tors, including excessive eruption of the maxillary inci-sors, vertical maxillary excess including a posteriorgummy smile, a short upper lip, and hyperactivity ofthe elevator muscles of the upper lip.14,15 The principalfactor in this patient seemed to be the excessiveeruption of the maxillary incisors (central incisors tostomion, 8.0 mm). Thus, we believed that if the

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extruded maxillary incisors were intruded, the gummysmile would be improved after the remodeling of thealveolar bone and the gingivae of the incisors.

Creekmore and Eklund12 were the first to reportintrusion of the maxillary incisors with a TSAD whenthey used a surgical vitallium bone screw. Ohnishiet al13 reported maxillary incisor intrusion using a mini-screw. Clearly, TSADs can intrude the maxillary incisorswithout side effects: ie, without extrusion of the maxil-lary molars or the undesirable clockwise rotation of themandible. Recently, Lin et al16 reported simultaneousreduction in the vertical dimension and improvementof a gummy smile using miniscrews. Especially innongrowing patients, intrusion mechanics with TSADsare the most effective and useful method available tous at this time and compare favorably with conventionalorthodontic therapies.

In our patient, the maxillary incisors were success-fully intruded by 3.5 mm, and the gummy smileimproved without side effects. The maxillary molarswere intruded by 1.5 mm. In addition, the intrudedincisors and molars showed no relapse at the 2-year

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Nishimura et al 93

follow-up. Riedel17 suggested that a large interincisalangle at the end of treatment was associated withrelapse of a deepbite. The patient's interincisal anglewas reduced by 21.5� during orthodontic treatment. Ac-cording to the literature to date, the relapse rates aftermaxillary molar intrusion and maxillary incisor intrusionrange from 10% to 30%18-20 and 20% to 60%,21-26

respectively. These authors also reported that intrudedmolars are less stable than are mesiodistal movementand rotation because no effective method for retentionhas been developed. It has been suggested thatintrusion should be performed slowly to allow forneuromuscular adaptation, overcorrection, and activeretention, and that this strategy will assist instabilizing the intrusive molars.17,20

After distalization of the maxillary molars, the Class IImolar relationship was successfully corrected in this pa-tient. It has been reported that the average amount ofdistalization of the maxillary first molars with miniplatesis 3.8 mm at the crown level.27 In this patient, distaliza-tion of the maxillary first molar was 4.0 mm. The maxil-lary molars were predictably distalized in accordancewith the treatment goals established before the ortho-dontic treatment. The biomechanics of the skeletalanchorage system with miniplates for distalization aresimpler than those for miniscrews because miniplatesare fixed outside the dentition. Since miniplates do notdisturb tooth movement in any way, the skeletalanchorage system makes simultaneous 3-dimensionalcontrol of the maxillary and mandibular teeth possible.Since the miniplate is one of the most reliable TSADs,the treatment goal can be predictably achieved, with lit-tle difference between the objectives established beforetreatment and the outcome of treatment.

For the bodily distalization of the posterior teeth,lever arms were extended from the main arch to bringthe line of force closer to the center of resistance, ineffect limiting the length of the lever arm because ofthe soft-tissue impingement. In this patient, the line oforthodontic force was expected to be below the centerof resistance of the whole maxillary dentition. As aresult, it was expected that extrusion of the anteriorteeth and intrusion of the posterior teeth would induceclockwise rotation of the occlusal plane. Extrusion ofthe anterior teeth was considered particularly undesir-able because it would only worsen the gummy smile.The miniscrew implanted between the root apices ofthe maxillary central incisors and the intruding leverarm were required for prevention of undesirable side ef-fects that are sometimes associated with distalization ofthe posterior teeth and correction of a gummy smile.Because the surgical intervention required for the inser-tion of a miniscrew is relatively minor and because it is

American Journal of Orthodontics and Dentofacial Orthoped

possible to intrude the anterior teeth without undesir-able side effects with a miniscrew, a miniscrew is consid-ered to provide the most effective mechanism topredictably intrude the anterior teeth.

In an orthodontic treatment that requires distaliza-tion to correct the molar relationships and intrusion tocorrect a gummy smile, it is possible to predictablyachieve treatment goals using a combination of TSADs:miniplates and a miniscrew.

CONCLUSIONS

Thanks to a combination of TSADs, miniplates, anda miniscrew, the correction of this patient's Class IIDivision 2 malocclusion with a gummy smile was suc-cessfully achieved without premolar extractions, or-thognathic surgery, and the need for patientcompliance.

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