Journal of the World Federation of Orthodontists 1 (2012) e79ee86

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Journal of the World Federation of Orthodontists

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Case Report

Treatment of Class II malocclusion with noncompliance miniscrew

implantesupported distalization system
Prabhat KC*, Sandhya Maheshwari, Sanjeev Kumar Verma, Mohammad Tariq, Syed Naved Zahid
Department of Orthodontics and Dental Anatomy, Aligarh Muslim University, Aligarh, India

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.

1. Introduction distalization system (MISSJDS) was used for nonextraction treat-

Class II malocclusion is the most frequent treatment problem in
an orthodontic practice. Treatment options of Class II malocclusion
include extraoral headgears, functional appliances, and conven-
tional full-fixed appliances with intermaxillary elastics or
combined with tooth extractions. Headgears can be adjusted to
provide a distalization force on the Class II side [1e3]. Removable
appliances designed to distalize molars have been advocated, but
both approaches require much patient cooperation [4,5]. Fixed
functional devices can provide a distalization force to the maxillary
posterior teeth, but also influence the mandibular dentition [6,7].
Pendulum appliances and distal jets have been advocated and
proven successful for molar distalization. However, there are
disadvantages, including laboratory time and expenses. Despite the
use of different components in the design of the appliance to
prevent the anchorage loss, flaring of the anterior teeth and
increased overjet (anterior anchorage loss) usually take place to
a significant extent.
Recently, miniscrew implants have been used clinically as
temporary stationary anchorage for various orthodontic move-
ments, because of their ability to provide absolute anchorage [8,9].
In this case report, the miniscrew implantesupported sliding jigs
ment of a patient with a Class II malocclusion to distalize the
maxillary molars in an invisible, noncompliant, and efficient way,
without mesial movement and proclination of the anterior teeth.
The MISSJDS consists of one active unit and one anchorage unit.
The active unit uses sliding jigs (Figs. 1) attached bilaterally in 0.020-
inch maxillary arch wire in 0.022- by 0.028-inch bracket slot and
a closed coil nickel titanium spring. The anchorage unit uses min-
iscrew implants in the alveolar bone between the maxillary first
molar and second premolar for temporary and stationary anchorage
to resist the anteriorly oriented reciprocal forces during molar dis-
talization and anterior teeth retraction. The nickel titanium coil
spring is attached between jigs and miniscrew implants bilaterally to
provide necessary force for molar distalization (Fig. 1). The point of
force application of buccal positioned closed coil nickel-titanium
springs of the MISSJDS passes through the center of resistance of
the maxillary molar; therefore, an almost pure bodily distal move-
ment is produced, and distal molar crown tipping can be avoided.
This case report describes a 16-year-old male patient who pre-
sented to our university orthodontic center with the chief
complaint of protruding upper front teeth. There was no significant
dental history and his medical history did not have any contrain-
dication to orthodontic treatment.

2. Diagnosis and etiology

* Corresponding author: Assistant Professor, Department of Orthodontics
and Dental Anatomy, Dr. Z.A. Dental College, Aligarh Muslim University, Aligarh,
India -212001. Extraorally, the patient had a normal facial form with no
E-mail address: dr.prabhatkc@gmail.com (Prabhat KC). asymmetries with the protrusion of upper lip and deep mentolabial

2212-4438/$ e see front matter Ó 2012 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2012.07.003
e80 Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86
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
side and Class II tendency on right side with maxillary dentoal-
veolar protrusion (Figs. 2 and 3). He had mild mandibular crowding,
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).
The panoramic radiograph (Fig. 4) revealed no evidence of bony
pathology. All 32 teeth were present. After obtaining orthodontic
records, the patient was advised to have all 4 third molars extracted,
which was recommended by his oral surgeon; however, the patient
was not willing to have extraction. The lateral cephalometric
radiograph (Fig. 4) and analysis (Table 1) demonstrated a skeletal
Class II malocclusion (A point, nasion, B point [ANB] ¼ 4 ) with
severe maxillary dentoalveolar protrusion and normally placed
mandibular incisors (Mx1eNA ¼ 45 /12 mm; Md1eNA ¼ 26 /
5 mm; interincisal angle ¼ 104 ). The sella nasion (SN)-mandibular
plane angle of 25 and Frankfort mandibular plane angle (FMA) of
17, indicated that the skeletal pattern was hypodivergent. A study
model analysis revealed a 6-mm space requirement in the maxillary
arch and 5-mm space requirement in the mandibular arch.
2.1. Treatment objectives
Treatment objectives for this patient were as follows:
1. Correct the maxillary dentoalveolar protrusion, because it was
his chief complaint.
2. Improve the skeletal hypodivergent profile.
3. Establish Class I molar and canine relationship.
4. Relieve the crowding in mandibular arch.
5. Correct the midline shift.
6. Create ideal overbite and overjet.
7. Ultimately establish a proper soft tissue profile.
2.2. Treatment alternatives
The patient’s chief concern was the protruding maxillary
incisors, and his parents wanted retraction of the maxillary
anterior teeth. Initially, a treatment plan was discussed, involving
extraoral headgear to be used for the maxillary molar distaliza-
tion and as a maximum anchorage device for the retraction of the
anterior teeth, but the patient was more concerned about his
facial appearance. The patient and his parents rejected this
treatment option. A second treatment option was discussed,
involving extraction of the maxillary first permanent premolars,
retraction and intrusion of the anterior teeth, and leveling and
alignment of the dental arches with conventional full-fixed
appliances and possibly intermaxillary elastics. This option was
also rejected by the patient’s parents, because they were against
extraction of healthy teeth for orthodontic purposes, and the
patient was reluctant to wear intermaxillary elastics. A third
treatment option was discussed, involving the use of functional
appliance(s) to advance the mandible for the correction of molar
relation and to achieve normal overjet and overbite. The visual
treatment objective (VTO) was evaluated and profile improve-
ment was negative due to patient prominent chin button. For the
treatment with this approach reduction genioplasty was advised
after mandibular advancement with the functional appliance. But,
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

Fig. 2. Pretreatment facial and intraoral photographs.

so this plan was also declined. Thus, a final alternative involving
distalization of the maxillary molars with the MISSJDS (Fig. 1) and
en-masse retraction and intrusion of the anterior teeth was dis-
cussed. This treatment plan was selected by the patient and his
parents.
2.3. Treatment progress
A 0.022-inch Roth edgewise appliance (Leone, Anaheim, CA) was
used. Initially, the maxillary and mandibular arches were banded
and bonded. A 0.016-inch nickel-titanium (Ni-Ti) archwire ligated

Fig. 3. Pretreatment study models.

e82 Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86

Table 1
Pretreatment and posttreatment lateral cephalometric analysis data

Measurement Pretreatment Posttreatment

SNA angle ( ) 80 80
SNB angle ( ) 76 76
ANB angle ( ) 4 4
Wits appraisal (mm) 1 1
FMA ( ) 17 21
SN-Go Gn ( ) 25 28
Bjork sum ( ) 383 385
Upper incisor to NA (mm) 11 6
Upper incisor to NA ( ) 45 30
Lower incisor NB (mm) 5 6.5
Lower incisor to NB ( ) 26 29
IMPA ( ) 100 102
Interincisal angle ( ) 104 124
Upper lip to E line (mm) 1 3
Lower lip to E line (mm) 4 3

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.

in maxillary and mandibular arches was used for initial alignment

and treatment progressed to a heavy archwire. Six months were
spent in the alignment phase until 0.019-inch by 0.025-inch Ni-Ti
upper and lower archwire was used. Then a 0.020-inch maxillary
archwire was placed and distalization of the maxillary molar was
achieved using the MISSJDS (Fig. 1). Under infiltration local anes-
thesia, a titanium alloy miniscrew (1.5-mm diameter and 8-mm
length for upper arch [SK Surgicals, Pune, Maharashtra, India])
was inserted into the buccal alveolar bone between the maxillary
second premolar and first molar (Fig. 1). After the placement of the
miniscrew implants, sliding jigs attached bilaterally in the 0.020-
inch maxillary arch wire in a 0.022- by 0.028-inch bracket slot.
The nickel titanium coil spring is attached between the jigs and the
miniscrew implants bilaterally to provide necessary force for molar
distalization with initial activation of 200g bilaterally. After initial
activation of the MISSJDS, the patient was monitored at 4-week
intervals for further adjustments and reactivation of the appli-
ance. With only the MISSJDS, the maxillary first molars were dis-
talized until a Class I molar relationship was achieved (Fig. 5) in
about 4 months. At the time, the molar relationship was corrected
to Class I on both sides, the retraction of premolar and canine was
Fig. 4. Pretreatment panoramic and lateral cephalometric radiographs.
achieved using indirect anchorage by placing another miniscrew
between the maxillary first molar and second molar. After the en-
masse anterior tooth retraction, the finishing phase began 2
months later by placing new 0.016- by 0.022-inch stainless steel
wires in both arches for final alignment of the teeth and detailing of
the occlusion (Fig. 6). The MISSJDS and the fixed appliances were
removed after a total treatment time of 18 months; a nice posterior
intercuspation and a well-functioning, stable occlusion was estab-
lished (Figs. 7 and 8). The miniscrews were stable during treatment
and were also removed at the same appointment.
After debonding and debanding, a lingual fixed retainer was
bonded to the mandibular anterior teeth from canine to canine
(Fig. 7). Maxillary retention was accomplished with removable
acrylic retainers. The patient was instructed to wear the retainers
for 2 months on full-time basis and thereafter at night only.

Fig. 5. Intraoral photograph of the patient after distalization.

 Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86 e83

Fig. 6. Intraoral photographs 14 months after the start of treatment.

2.4. Treatment results
Dentoalveolar protrusion, which was the patient’s chief
complaint, was eliminated with the establishment of ideal overbite
and overjet relationships. Correction of overbite improves the
condition of palatal mucosa. The midline deviation was corrected,
and the dental midlines were aligned with facial midline. Posterior
occlusal relationships were improved to achieve Class I canine and
Class I molar relationships on both sides with good functional
occlusion.
The photographs in Fig. 7 show a much-improved profile. The
upper lip has been retracted about 2 mm, with respect to the E lines,

Fig. 7. Posttreatment facial and intraoral photographs.

e84 Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86
Fig. 8. Posttreatment study models.
and the lips are competent. The smile was improved, with less
amount of gingival exposure. The cephalometric analysis (Fig. 9 and
Table 1) and superimposition (Fig. 10) revealed a significant amount
of vertical dental and skeletal changes during the treatment period,
which is seen on cephalometric superimpositions (Fig. 10 and
Table 1). The maxillary incisors were intruded 1.5 mm and retracted
4 mm in a bodily manner from the initial position. In the mandible,
the crowding of the lower incisors was resolved and the incisors
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
Fig. 9. Panoramic and lateral cephalometric radiographs just before debonding.
in the intercanine width in the maxilla and in the mandible,
whereas, the intermolar width increased by 1 mm in both the
maxilla and the mandible. The dental and periodontal health was
good and the panoramic radiograph (Fig. 9) examination indicated
satisfactory root paralleling except for the distal root angulation of
tooth 34 without any tissue loss.
3. Discussion
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
extractions and without the need for patient cooperation, except for
 Prabhat KC et al. / Journal of the World Federation of Orthodontists 1 (2012) e79ee86
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
distalize the maxillary molars and later used with conventional full-
fixed orthodontic appliances to retract and intrude the anterior
teeth, allowed the total orthodontic treatment to achieve a stable,
functional occlusion with good posterior intercuspation and bilat-
eral Class I molar and canine relationship. In addition, the lips
competence and facial balance were improved.
Nevertheless, a unique advantage of the MISSJDS is that the
same miniscrew implants can be used for temporary and stationary
anchorage to support both molar distalization and anterior tooth
retraction, after a slight chair-side modification (Fig. 11). When
using the MISSJDS, special attention should always be given to
positioning the implants far from the roots of the anterior teeth, not
only to present an initial clearance of 2 mm, which is needed to
prevent their contact with the roots of adjacent teeth if the
implants move slightly during treatment [9], but also to present
a safe distance of 4 to 5 mm between the miniscrew implants and
the roots of the adjacent teeth, which is necessary for the retraction
of the anterior teeth after molar distalization. This safety clearance,
along with placement of the miniscrew implants, ensured that
there was enough bone, both quantitative and qualitative, to hold
Fig. 11. Modification of the MISSJDS.
e85
the implants in place and prevent contact with the roots of the
anterior teeth during or after their retraction. Thus, the side effects
of anchorage loss of the anterior dental unit during molar dis-
talization and the posterior anchorage loss in terms of mesial molar
movement during anterior tooth retraction with conventional dis-
talization devices are eliminated with the use of the MISSJDS. If 4 to
5 mm of safety clearance is not present between the miniscrew
implants and the roots of adjacent teeth, another implant should be
used between maxillary first and second molar to stabilize the
molar after distalization and to provide indirect or direct anchorage
for anterior teeth retraction.
4. Conclusions
This case report demonstrates the efficient clinical use of the
miniscrew implants not only to distalize the maxillary molars but
also to retract the anterior teeth with full-fixed appliances,
providing an easy, noncompliance, nonextraction, and efficient
approach for the complete orthodontic treatment of patients with
Class II malocclusion.
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