CASE REPORT

Miniscrew mechanics for molar

distalization and incisor intrusion in a
patient with a Class II brachyfacial
pattern and gummy smile
 nica Garcıa-Sanz
Vanessa Paredes-Gallardo, Carlos Bellot-Arcıs, and Vero
Valencia, Spain

A gummy smile is one of the most problematic characteristics in patients with a Class II Division 2 malocclusion,
and the correction of vertical position and incisor torque is often challenging for the orthodontist. This case report
describes the orthodontic treatment of a 31-year-old woman, assisted by miniscrew mechanics for maxillary arch
distalization and correction of a gummy smile with a brachyfacial pattern. Two different mechanics were used.
Miniscrews were placed in both maxillary tuberosities, and the maxillary arch was successfully distalized, cor-
recting the Class II relationship. Interradicular miniscrews were placed for maxillary and mandibular incisor intru-
sion to correct the gummy smile, overbite, and torque. Finally, periodontal surgery was performed to lengthen the
maxillary incisor crowns. Satisfactory smile esthetics and good occlusion were achieved. Follow-up after
24 months confirmed that the outcome was stable. (Am J Orthod Dentofacial Orthop 2020;-:---)

O
ne of the most challenging objectives in the the cause is anterior maxillary excess, with LeFort I os-
treatment of patients with Class II Division 2 teotomy being the most common procedure.4 When sur-
malocclusion is to correct the vertical position gical treatment is not an option because of the patient's
and maxillary incisor torque.1 In these patients, the ret- unwillingness to undergo the procedure, or when there
roclination of the maxillary incisors is a consequence of is no skeletal maxillary vertical excess, the use of
the high pressure exerted by the lower lip, making intru- miniscrews should be considered as this offers an
sion and torque important treatment goals, together effective method for attaining maxillary incisor intrusion
with their long-term stability.2 and so correction of the gummy smile.5
In addition, some of these patients present excessive Miniscrews offer the advantages of immediate loading,
gingival display, resulting in a gummy smile and the multiple placement sites, relatively simple placement
consequent poor esthetics. For these patients, diagnosis and removal, and minimal expense.6,7 When placing
and treatment planning must fulfill both orthodontic miniscrews in the anterior interradicular areas, in
objectives and the patient's expectations. combination with appropriate orthodontic mechanics,
The decision to treat this vertical malocclusion with the intrusion of maxillary and mandibular incisors can
either orthodontics alone or in combination with or- be achieved, improving overbite.8,9
thognathic surgery will depend on the etiology and In addition, mechanics for maxillary molar distaliza-
severity of the problem along with other individual fac- tion to correct a Class II malocclusion can be simplified
tors.3 Orthognathic surgery is a common approach when by placing miniscrews in the maxillary tuberosity.
Although this area is not ideal because of poor bone
quality, the implementation of proper placement proto-
From the Orthodontics Teaching Unit, Department of Stomatology, Faculty of
cols and biomechanical design can lead to outstanding
Medicine and Dentistry, University of Valencia, Valencia, Spain.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- results.10
tential Conflicts of Interest, and none were reported. If there is a deficiency in the upper lip length,
Address correspondence to: Ver onica Garcıa-Sanz, Orthodontics Teaching Unit,
cosmetic techniques such as lip repositioning can obtain
Department of Stomatology, Clınica Odontol ogica, Universitat de Valencia, C/
Gasco Oliag 1, Valencia 46010, Spain; e-mail, [email protected]. good results in terms of gingival display,11 although this
Submitted, March 2019; revised and accepted, April 2019. treatment might show some relapse.12
0889-5406/$36.00
When the patient presents reduced maxillary central
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.04.038 incisor crown height because of altered passive eruption,

1
2 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz

periodontal surgery can be performed to lengthen the to stomion, although there was an alteration in lip
incisors' clinical crowns, which will improve the gum- mobility; the excessive difference between the position
teeth relationship.13 of the patient's upper lip at rest and full smile indicated
This case report describes the nonsurgical orthodontic upper lip hypermobility.
correction of a brachyfacial pattern with Class II Division Intraoral photographs and study models show an
2 malocclusion and excessive gingival display treated incomplete molar and canine Angle Class II relationship.
with miniscrews for maxillary and mandibular incisor The overjet and overbite were 3.6 mm and 7.3 mm,
intrusion, and molar distalization to provide adequate respectively. Mandibular dentition showed an excessive
vertical position and incisor torque. Treatment enhanced curve of Spee because of the overeruption of the
smile esthetics and provided good long-term stability. mandibular incisors. The maxillary dental midline was
deviated to the right concerning the facial midline,
whereas the mandibular dental midline was centered
DIAGNOSIS AND ETIOLOGY concerning the mandible, so maxillary and mandibular
A 31-year-old woman complaining of a gummy smile dental midlines did not match. The arch discrepancy in-
and maxillary incisor crowding visited the clinic seeking dex was 7.1 mm and 3.5 mm for the maxillary and
orthodontic treatment. mandibular arches, respectively. The maxillary central
The frontal facial photograph shows a gingival incisor crown height was short (7.9 mm), and the 4
display of 4-5 mm. The maxillary incisal exposure at maxillary incisors presented altered passive eruption
rest was slightly excessive. The patient's facial profile (Figs 1 and 2). The patient's periodontal examination
was convex, and the upper lip appeared protruded. There indicated good periodontal conditions.
was scarce chin projection, and her mentolabial angle Cephalometric analysis (Fig 3, A and B; Table)
was obtuse (Fig 1). The upper lip length was within the showed a skeletal Class II (ANB, 5.6 ) with a severe bra-
normal range, measuring 22 mm from subnasale chyfacial pattern (facial axis, 94.3 ; FMA, 25.1 ; lower

Fig 1. Pretreatment facial and intraoral photographs.

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Fig 2. Pretreatment study models.

lower facial height, 71.6 mm). The maxillary and TREATMENT ALTERNATIVES
mandibular incisors were lingually inclined (PP-U1, The orthognathic surgical approach, such as LeFort
91 ; IMPA, 76.1 ), and as a result, the interincisal angle impaction, was not considered in this patient, because
was increased (164.1 ). the gummy smile was not due to anterior vertical maxil-
The third molars had already been extracted by the lary excess.
oral surgeon at an earlier date (Fig 3, C). Orthodontic treatment options involving extraction
Based on these findings, the patient was diagnosed and nonextraction can be contemplated for Class II Divi-
as presenting a brachyfacial pattern with skeletal and sion 2 malocclusion in an adult presenting negative arch
dental Class II Division 2, excessive overbite and overjet, discrepancy. To avoid extractions, effective molar distal-
increased curve of Spee, and excessive gingival display ization may be performed. However, when no distaliza-
with an altered passive eruption of the maxillary incisors. tion is desired or cannot be performed because of the
Periodontal health was good. presence of third molars, maxillary premolar extractions
must be carried out to avoid excessive proinclination of
the maxillary incisors, leaving a molar Class II and canine
Class I malocclusion. The patient did not want any
TREATMENT OBJECTIVES premolar extraction, and because third molars were
The treatment plan focused on achieving optimal not present, a non-extraction treatment was chosen.
overjet and overbite, incisor torque, and on improving Miniscrews may be used to correct a gummy smile
the gummy smile to provide adequate esthetics, func- successfully, and to flatten the curve of Spee. Conven-
tion, and long-term stability, in the shortest possible tional orthodontic methods, such as intrusion arches,
treatment duration, without any need for patient utility arches, extraoral appliances, or rubber bands,
compliance. can lead to undesirable side effects and also depend
Treatment objectives were (1) to establish a skeletal on patient cooperation. These unwanted side effects
and dental Angle Class I relationship, (2) to flatten the are extrusion and flaring of the posterior teeth, and
curve of Spee to achieve a harmonious smile, (3) to the clockwise rotation of the mandible caused by the
reduce the gummy smile aiming at a more attractive extrusion of the posterior teeth, which will worsen the
smile, (4) to obtain adequate incisor torque, and (5) to Class II convex profile in many patients and also lead
attain a balanced facial profile. to an increase in the incidence of relapse in adults.14,15

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Fig 3. Pretreatment records: A, lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.

Maxillary central incisor crown height was short due preferences, whereas 0.022 3 0.028-in slot metal appliance
to maxillary incisor altered passive eruption, so maxillary system (Victory Series; 3M Unitek) was used on the mandib-
incisor periodontal surgery was planned. Because maxil- ular arch. MBT prescription was chosen for both maxillary
lary central incisor anatomy was appropriate, composite and mandibular bracket appliances.
restorations were not a good option. The treatment plan was developed in 2 stages. The
Finally, because of the hypermobility of the upper lip, initial phase involved the insertion of a miniscrew into
the possibility of Botox or lip repositioning procedures each maxillary tuberosity to correct the Class II malocclu-
were considered and proposed to the patient. Neverthe- sion (length, 12 mm; diameter, 2 mm; Jeil Medical Corpo-
less, these treatments are not always stable.12 In the end, ration, Seoul, Korea) (Fig 4, A and B). These screws were
these procedures were not necessary because, after or- inserted under local anesthesia at the start of treatment.
thodontic treatment, the correction of the gingival smile Figure 4, C shows the diastema produced by the distaliza-
was satisfactory. tion effect of the miniscrews. After 6 months, a Class I rela-
tionship was achieved, so the miniscrews were removed.
TREATMENT PROGRESS In the second phase, 2 more miniscrews were placed
A 0.022 3 0.028-in slot preadjusted edgewise-ceramic in the maxillary incisor area to obtain intrusion of the
appliance was placed on the maxillary arch (Clarity maxillary incisors and to correct the gummy smile
Advanced; 3M Unitek, Monrovia, Calif) because of patient (length, 10 mm; diameter, 1.8 mm; Jeil Medical

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inserted in the interradicular areas under local anesthesia

Table. Pretreatment, posttreatment, and postreten-
perpendicular to the teeth to endure the intrusion forces.
tion cephalometric summary
After 4 months, the intrusion of the anterior teeth was
Cephalometric attained, so the miniscrews were removed.
analysis Pretreatment Posttreatment Postretention
SNA angle ( ) 83.1 82.9 83.0 Miniscrew mechanics
SNB angle ( ) 77.5 78.3 78.1
ANB angle ( ) 5.6 4.6 4.5 Maxillary arch distalization is shown in Figure 6, A.
Wits appraisal (mm) 4.7 0.2 0.0 Miniscrews were used as direct anchorage units, and
U1-palatal plane ( ) 91.0 109.7 110.0 force was applied to the teeth with a power chain. The
IMPA (L1-Mp) ( ) 76.1 96.5 96.5
Interincisal angle ( ) 164.1 128.3 128.0
miniscrew heads should all be the same level as the molar
Overjet (mm) 3.6 2.2 2.2 bracket to avoid producing molar intrusion (Fig 4, A).
Overbite (mm) 7.3 1.0 1.1 The same power chain with 5 links was used to pull
Facial axis 94.3 96.3 96.0 the first and second molars simultaneously. An initial
(NaBa-PtGn) ( ) 50 g of force was applied to the molars during the first
FMA (Mp-FH) ( ) 25.1 23.0 23.0
Upper facial height 48.0 48.0 48.0
month, later increased to 100 g of force. To avoid the
(N-ANS) (mm) side effects of 1-side traction, we added lingual attach-
Lower facial height 71.6 70.0 70.2 ments to the posterior teeth, so traction could be per-
(ANS-Me) (mm) formed from both buccal and lingual sides as needed.
Mandibular length 76.0 76.0 76.0 The arch expansion was attained by applying higher
(Go-Gn) (mm)
Upper lip length 22.3 22.0 22.1
forces to the lingual chain. The archwire should be
(Sn-StSup) (mm) long enough to allow molar distalization, bent at a dis-
tance, so that it does not cause discomfort to the patient.
Mandibular incisor intrusion is shown in Figure 6, B.
Corporation), whereas 1 single miniscrew (length, Miniscrews were also used as direct anchorage units,
10 mm; diameter, 1.8 mm; Jeil Medical Corporation) applying a light force to the archwire (5-15 g of force),
was placed in the mandibular incisor area to flatten in this case with an elastic thread. One single miniscrew
the curve of Spee (Fig 5, A and B). The screws were was placed between mandibular central incisors, located

Fig 4. Mechanics for maxillary arch distalization using min-

iscrews placed in the maxillary tuberosity: A, illustration of
miniscrew inserted in the tuberosity; B, miniscrews placed Fig 5. Mechanics for maxillary and mandibular incisor
distal to maxillary molars and elastic chains for distalization; intrusion using miniscrews: A, intraoral photograph; B,
C, diastemas produced by distalizing mechanics. periapical radiographs.

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anterior to the center of resistance, aiming to achieve were bonded on both arches, and thermoplastic retainers
intrusion as well as labial tipping of the incisors. were provided to be worn at night.
Maxillary incisor intrusion is shown in Figure 6, C.
Light forces were also applied (5-15 g of force) with an
elastic chain. Because both miniscrews were placed pos- TREATMENT RESULTS
terior to the center of resistance, intrusion with less Because of the implementation of 2 types of
labial tipping was expected. miniscrew mechanics (2 miniscrews for Class II correc-
Orthodontic alignment and leveling were achieved us- tion by molar distalization, and 3 for incisor intrusion,
ing nickel-titanium 0.014-in, 0.016-in, 0.019 3 0.025-in gummy smile reduction, and flattening the curve of
and 0.021 3 0.025-in archwires, whereas stainless steel Spee), the patient's malocclusion greatly improved,
0.016-in, 0.019 3 0.025-in and 0.021 3 0.025-in arch- and the orthodontic treatment time was significantly
wires were employed to correct the dental arches. Addi- shortened with no need for patient compliance.
tional torque to the maxillary incisors was necessary An acceptable occlusion and a satisfactory facial pro-
during treatment, so Warren torquing springs (Rocky file were also obtained. Posttreatment facial photo-
Mountain Orthodontics, Denver, Colo) were used in combi- graphs showed that a balanced and harmonious face
nation with the stainless steel 0.021 3 0.025-in archwires. was achieved (Fig 8). The patient was very satisfied
Intermaxillary 0.25-in elastics were used for Class II with the treatment results, which completely fulfilled
and midline correction. Short triangular intermaxillary her expectations. The mentolabial angle improved
0.125-in elastics (super thread; Rocky Mountain significantly, providing better esthetics to the facial
Orthodontics) were used to obtain premolar and canine profile by increasing chin projection.
interdigitation. Posttreatment intraoral pictures and dental cast
Just before removing the fixed appliances, peri- models illustrate good dental interdigitation. In addi-
odontal surgery of the central and lateral maxillary tion, an Angle Class I molar relationship and an accept-
incisors was performed to lengthen the clinical crowns able interincisal relationship were established. The
because they presented altered passive eruption, and gummy smile was substantially reduced (Figs 8 and 9).
the crowns were short. Accurate evaluation of the excess The cephalometric analysis also showed significant
of the keratinized tissue was conducted to determine the changes to the patient's measurements (Figs 10, A and
amount to be removed, in consideration of the crown B; Table). The ANB angle decreased from 5.6 to 4.6 ,
proportions (Fig 7). and the Wits appraisal from 4.7 mm to 0.2 mm. This
The total duration of the orthodontic treatment was discrepancy between the ANB angle and the Wits
approximately 20 months. After removing the orthodon- appraisal was due to the counter-clockwise rotation of
tic appliances, canine-to-canine fixed lingual retainers the occlusal plane because the mandibular plane

Fig 6. Illustrations of the mechanics used: A, maxillary arch distalization; B, mandibular incisor intru-
sion; C, maxillary incisor intrusion.

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Figure 11 shows superimpositions of pretreatment and

posttreatment digital dental models, which demonstrate
that at the end of treatment, the overerupted mandibular
incisors were significantly corrected and intruded, and the
excessive curve of Spee was also flattened. The difference
in torque and vertical position of maxillary incisors before
and after treatment was also remarkable. Intrusions of
1.8 mm and 2.1 mm were achieved for maxillary and
mandibular incisors, respectively.
After a 24-month retention period, the facial es-
thetics and occlusion achieved at the end of treatment
Fig 7. Clinical crown lengthening of maxillary incisors. were perfectly maintained (Fig 12).
Postretention cephalometric analysis (Fig 13, A and B;
Table) showed no changes compared to posttreatment
confirmed. Maxillary and mandibular incisors were analysis (Fig 10, A and B; Table). In addition, the postreten-
buccally inclined (PP-U1, 109.7 ; IMPA, 96.5 ). Facial tion panoramic radiograph showed no changes (Fig 13, C)
pattern measurements changed significantly (facial compared to posttreatment analysis (Fig 10, C).
axis from 94.3 to 96.3 ; FMA from 25.1 to 23 ). Figure 14, A, B, and C show superimpositions of pre-
Acceptable root parallelism was achieved, and neither treatment, posttreatment, and postretention cephalo-
root resorption nor marginal bone loss in the periodontal metric tracings. These findings show the dental,
tissues were observed (Fig 10, C). Periodontal health skeletal, and soft tissue changes achieved as the result
remained sound throughout the treatment period. of treatment and stability in the postretention period.

Fig 8. Posttreatment facial and intraoral photographs.

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Fig 9. Posttreatment study models.

The intrusion and proclination of maxillary and mandib- overbite was caused by the overeruption of the incisors
ular incisors achieved at the end of treatment remained with the consequently increased curve of Spee. The
stable after the 24-month retention period. intrusion of the maxillary and mandibular incisors was
successfully performed using miniscrews without any
DISCUSSION side effects as reported by other authors,19,20 which
Chin projection and the mentolabial angle improved shortened treatment time and did not require patient
after treatment because of the counter-clockwise rota- compliance. By applying orthodontic mechanics with
tion of the mandible, so the patient's convex facial pro- miniscrews, 1.8 mm and 2.1 mm intrusions of the maxil-
file and protruded upper lip became straighter and more lary and mandibular incisors were achieved, respectively.
balanced. A gummy smile can be the result of a combi- These intrusion values are greater than those that can be
nation of factors including vertical maxillary excess, obtained using conventional techniques, as stated in a
small maxillary central incisor crown height, altered pas- meta-analysis conducted by Ng et al21 which concluded
sive eruption, a short upper lip, and a hyperactive upper that segmented arch techniques could produce 1.5 mm
lip.16 The main etiologic factors in the present case were and 1.9 mm of maxillary and mandibular incisor intru-
excessive incisor extrusion, altered passive eruption, and sion, respectively. One of the possible undesirable effects
hyperactivity of the upper lip. The maxillary central of intrusion mechanics is root resorption, which did not
incisor crown height was shorter than normal (7.9 mm) occur in the present case, as shown by the final pano-
because of altered passive eruption; the correct value ramic radiograph (Fig 10, A).
in an adult female was 9.6 mm.17 Although the upper Different mechanics can be applied for incisor intru-
lip appeared to be clinically short at the start of treat- sion, according to the orthodontic movement sought. A
ment, the distance from the subnasale landmark to the study by Lindauer and Isaacson22 shows the different ef-
stomion was 22 mm, which is within the normal range. fects that can be obtained from the point where force is
Interestingly, several studies have shown that in most applied concerning the center of resistance of the ante-
cases of excessive gingival display, the upper lip length rior teeth during intrusion and extrusion movements. In
is normal, although, the lip appears clinically short.18 the present case, for mandibular incisors, 1 miniscrew
Maxillary and mandibular incisor intrusion was 1 of was placed in the interradicular space between the 2
the main treatment objectives because the severe central incisors, this location being anterior to the center

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Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz 9

Fig 10. Posttreatment records: A, lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.

of resistance. In this way, the force applied produced less miniscrews was very stable, as a previous case report
intrusion but more buccal tipping, the desired move- has shown.23
ments for the lingually inclined mandibular incisors Warren torquing spring devices (Rocky Mountain Or-
(Fig 6, B). However, for maxillary incisor intrusion, 2 thodontics) were used to provide the additional maxil-
miniscrews were inserted. These were placed between lary incisor torque needed.24 Excessive linguoversion is
the roots of canines and lateral incisors, so the force usually caused by the pressure of the lower lip on the
was applied posterior to the center of resistance, produc- overerupted maxillary incisors. For this reason, achieving
ing less labial tipping but more intrusion to correct the the ideal maxillary incisor position and torque was 1 of
gummy smile (Fig 6, C). When placing the miniscrews, the main treatment goals in the present case, because
maxillary and mandibular convexity should be taken a good result in this area would provide long-term sta-
into consideration to avoid impingement of the elastic bility.2 As explained by Sarver and Ackerman,25 incisor
thread. proclination can have a dramatic effect on incisor
Because 1 of the main goals of the treatment was the display, which appears reduced if these teeth are exces-
correction of the gummy smile, the stability of the treat- sively flared. In the present case, incisor inclination
ment largely depended on the prevention of extrusion of provided good and harmonious smile esthetics.
the incisors. After the 24-month retention period, both Aiming to control maxillary incisor inclination, avoid
maxillary and mandibular incisor intrusion with excessive buccal tipping during alignment, and correct

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Fig 11. Superimposition of pretreatment and posttreatment digital dental models.

Fig 12. Postretention facial and intraoral photographs.

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Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz 11

Fig 13. Postretention records: A, lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.

the dental Class II malocclusion with minimum side ef- mechanics, a low rate of complications, minimal eco-
fects, miniscrews were placed in both maxillary tuberos- nomic cost to the patient, reduced treatment time,
ities to distalize the maxillary arch (Figs 4 and 6, A) versatility, and no need for patient compliance.
taking advantage of the fact that the third molars had As diagnosed before treatment, the passive eruption
been extracted at a much earlier date. Good results was altered. After careful evaluation of the keratinized
were obtained in this regard with none of the side effects soft tissue and alveolar bone level, periodontal surgery
reported by other authors,10 even though microscrew was conducted in the maxillary incisors to improve smile
placement in this area may lead to complications esthetics and provide ideal crown proportions. The
because of the poor quality of the bone, high morpho- integrity of the dentogingival junction must be re-
logic variation between patients,26 and the risk of maxil- spected to ensure good and stable outcomes; this will
lary sinus perforation. Although complications of this depend on detailed and accurate diagnosis.28 Satisfac-
type are rarely reported, a minimum sinus floor thickness tory results were obtained in this case, which remained
of 6.0 mm or more is recommended to avoid miniscrew stable throughout the retention period.
perforation of the maxillary sinus.27
In the present treatment, only a small number of
miniscrews were needed. These devices offered many ad- CONCLUSIONS
vantages such as no need for laboratory work, ease of The use of 2 different types of miniscrew mechanics
placement and removal, immediate load application, made it possible to correct the brachyfacial pattern with
minimal anatomic limitation, simple treatment Class II Division 2 malocclusion and a gummy smile. This

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Fig 14. Superimposed pretreatment (black line), posttreatment (red line), and 2 years postretention
(green line) cephalometric tracings: A, superimposed on the sella-nasion plane at sella; B, superim-
posed on the palatal plane at anterior nasal spine; C, superimposed on the mandibular plane at menton.

outcome was achieved successfully without premolar ex- 9. Wang XD, Zhang JN, Liu DW, Lei FF, Liu WT, Song Y, et al. Nonsur-
tractions. Orthodontic treatment time was significantly gical correction using miniscrew-assisted vertical control of a se-
vere high angle with mandibular retrusion and gummy smile in
shortened without any need for patient compliance. In
an adult. Am J Orthod Dentofacial Orthop 2017;151:978-88.
this case, the key to a successful outcome in terms of smile 10. Sada Garralda VJ. Simultaneous intrusion and distalization using
esthetics and long-term stability was the adequate posi- miniscrews in the maxillary tuberosity. J Clin Orthod 2016;50:
tioning and torque of the maxillary incisors. 605-12.
11. Faus-Matoses V, Faus-Matoses I, Jorques-Zafrilla A, Faus-
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