Combined Distalization and Lingual Cortex Remodeling During Mandibular Growth For Facial Profile Improvement: A Case Report

Case Report
Combined distalization and lingual cortex remodeling during mandibular

growth for facial profile improvement: a case report
Hai-Van Giapa; Ji Yoon Jeona; Joo-Hee Chuna; Kee-Joon Leeb
ABSTRACT
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Borderline crowding poses a challenge in deciding whether or not to prescribe premolar extraction. This
case report describes the two-phase nonextraction orthodontic treatment of an 11-year-old girl with a
hyperdivergent skeletal Class I pattern exhibiting anterior crowding and moderate lip protrusion. The initial
phase of treatment included maxillary and mandibular expansion to correct the transverse discrepancy as
an early intervention. Subsequently, comprehensive treatment was initiated at the age of 13 years, with
fully erupted permanent second molars and growth potential remaining. Phase II treatment involved a
second round of maxillary expansion, followed by simultaneous bimaxillary total arch intrusive distaliza-
tion, using interradicular, temporary skeletal anchorage devices to correct dental crowding and improve
the facial profile. Although the limited retromolar space posed a challenge to mandibular tooth distaliza-
tion, gradual bone remodeling was observed in the lingual cortex of the mandibular body, enabling suffi-
cient orthodontic tooth movement without noticeable side effects. After 4 years 3 months of treatment, her
dental crowding was relieved, with significant improvement in the facial profile and proper occlusion. The
treatment outcomes remained stable 2 years 4 months after retention. (Angle Orthod. 2024;94:353–365.)
KEY WORDS: Bone remodeling; Mandibular posterior lingual cortical plate; Simultaneous total
arch distalization and intrusion
INTRODUCTION (TSADs) can be effective and predictable treatment

approaches that do not require tooth extraction.2 How-
Decision-making regarding the appropriate treatment
ever, additional treatment options should be considered
modality, timing for extraction, or use of nonextraction
for improving the facial profile if dental crowding coex-
approaches is challenging when treating growing patients
ists with lip protrusion. Although unlimited orthodontic
displaying dental crowding.1 Nonextraction treatment is
distalization is not possible given the posterior anatomi-
often preferred by patients. In such cases, achieving har-
mony between the patient’s facial features and occlusion cal limit,3,4 alveolar bone can regenerate and may
requires strategic alignment in the treatment plan. potentially ensure the safety of this treatment.5,6
To correct mild to moderate dental crowding and This case is that of an 11-year-old girl who presented
minimal skeletal discrepancy, expansion and molar dis- with anterior crowding and lip protrusion. To correct den-
talization with temporary skeletal anchorage devices tal crowding and improve the facial profile, the patient
underwent two-phase nonextraction orthodontic treat-
ment by maxillary expansion and bimaxillary total arch
The first two authors contributed equally to this work. intrusive distalization. Although the limits of the posterior
a
Postgraduate Student, Department of Orthodontics, Institute alveolar housing pose a challenge to total arch distaliza-
of Craniofacial Deformity, College of Dentistry, Yonsei University, tion in the mandible, this case report presents evidence
Seoul, Republic of Korea. of bone remodeling in the posterior cortex of the mandib-
b
Professor, Department of Orthodontics, Institute of Craniofacial
Deformity, College of Dentistry, Yonsei University, Seoul, Republic ular lingual cortical plate, allowing adequate distalization
of Korea. of the teeth with minimal adverse effects.
Corresponding author: Kee-Joon Lee, DDS, MSD, PhD,
Professor, Department of Orthodontics, Institute of Craniofacial
Deformity, Yonsei University College of Dentistry, No. 723, 50-1 Diagnosis and Etiology
Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
(e-mail: [email protected]) An 11-year-old female patient complained of dental
Accepted: October 2023. Submitted: June 2023.
crowding and sought orthodontic consultation. No his-
Published Online: November 15, 2023 tory of systemic diseases or developmental anomalies
Ó 2024 by The EH Angle Education and Research Foundation, Inc. was recorded.
DOI: 10.2319/060123-390.1 353 Angle Orthodontist, Vol 94, No 3, 2024

354 GIAP, JEON, CHUN, LEE

Figure 1. Pretreatment photographs.
The initial examination revealed dental crowding of dentition with mild Class II molar and canine relation-
9 mm and 5 mm in the maxillary and mandibular den- ships. The patient had rotated lateral incisors and
tition, respectively. Extraoral photographs revealed a ectopically erupted canines in the maxillary arch.
convex profile with minor lip protrusion, and the den- The mandibular arch displayed a severe deep curve
tal midlines were coincident with the facial midline of Spee on both sides, with crowding of the anterior
(Figure 1). Intraoral examination indicated a mixed teeth. Additionally, a narrow maxillary arch was
Figure 2. Pretreatment dental models.
Angle Orthodontist, Vol 94, No 3, 2024

POSTERIOR LINGUAL CORTICAL PLATE REMODELING 355
Table 1. Cephalometric Analysis Measurementsa

Value
Phase II Treatment
Measurement Phase I Treatment, Pretreatment Pretreatment Posttreatment
SNA angle (°) 82.5 82.0 80.2
SNB angle (°) 78.0 79.0 81.0
ANB angle (°) 4.5 3.1 0.8
Wits appraisal (mm) 2.5 4.6 5.2
SN to mandibular plane (°) 36.3 42.5 38.7
FMA (°) 31.9 34.2 30.6
Bjork sum (°) 400.3 402.5 398.7

AFH (mm) 126.9 133.9 138.4
U1 to SN (°) 110.4 114.0 115.6
IMPA (°) 90.6 87.1 91.7
a
AFH indicates anterior facial height. (SNA: Sella-Nasion-A point, SNB: Sella-Nasion-B point, ANB: A point-Nasion-B point, SN: Sella-
Nasion, FMA: Frankfort-Mandibular plane Angle, IMPA: Incisor-Mandibular plane Angle)
noted, with compensated labiolingual inclinations of 39.6 mm in the lower arch, respectively). The overjet
the maxillary and mandibular molars (intercanine and overbite were 3 mm and 1.5 mm, respectively.
and intermolar widths at the crown level of 35.7 mm The patient exhibited good oral hygiene (Figures 1
and 44.4 mm in the upper arch and 29.0 mm and and 2).
Figure 3. Pretreatment radiographs and cephalometric tracing.


Figure 4. Images obtained during phase I treatment (A) and at the end of phase I treatment (B).
Lateral cephalometric analysis revealed a hyperdi- Treatment Objectives

vergent Class I skeletal pattern with normal labiolin-
The treatment objectives were to correct the dental
gual inclination of the upper and lower incisors (Table 1).
crowding, establish proper occlusion, and improve the
The patient was at the third to fourth cervical vertebral
patient’s facial esthetics.
maturation stage, ie, circumpubertal (Table 1; Figure 3).
A panoramic radiograph showed no congenitally missing Treatment Alternatives
teeth or signs of abnormal permanent tooth eruption Two treatment options were presented to the patient
(Figure 3). and her parents:
Based on these findings, the patient was diagnosed
with a hyperdivergent skeletal Class I malocclusion 1. Extraction of four first premolars would address
with a transverse discrepancy. dental crowding and offer a quicker treatment with


Figure 5. Radiographs and cephalometric tracing at the initiation of phase II treatment.
an improved facial profile. However, challenges Treatment Progress

might have arisen in closing the extraction spaces
Miniscrew-assisted rapid palatal expansion (MARPE)
with upright incisors, particularly in the mandibular
was used for phase I treatment. Compared to conven-
arch. tional rapid palatal expansion, MARPE has been found
2. As the patient and her parents did not want tooth to play a critical role in preventing the buccal displace-
extractions, a nonextraction approach was consid- ment of anchor teeth within the basal bone during consol-
ered to address the patient’s chief complaint of idation, ensuring periodontal safety with a more stable
dental crowding. Due to the patient’s premenar- treatment outcome. Consequently, the negative side
chal status, this treatment plan would involve two effects of maxillary expansion, including thinner buccal
phases, early intervention and comprehensive bone plates, changes in the crestal bone levels of the
treatment, and the arch length deficiency would banded teeth, and short-term skeletal relapse, were elim-
be resolved by transverse and anteroposterior inated.7,8 A Schwartz appliance was used to address the
arch expansion. However, this option required a space deficiency in the mandibular arch (Figure 4A).
longer treatment period, and potential side effects The MARPE device was delivered with two TSADs
such as relapse and bony dehiscence had to be (self-drilled type, 1.8 mm in diameter and 7.0 mm in
considered.7 length; Orlus, Ortholution, Seoul, Republic of Korea)


Figure 6. Intraoral photographs and CBCT images taken during phase II treatment. (A) Maxillary expansion. (B) Leveling and alignment.
on the anterior side of the jackscrew, and the first pre- second molars to monitor skeletal and facial growth
molars and the first molars were utilized as anchor (Figure 4B).
teeth (Figure 4A). The patient was instructed to turn Phase II treatment was initiated when the patient
the jackscrew one quarter-turn (0.2 mm/turn) once was 13 years old. At this time point, aside from the
daily for the MARPE device and once every 5 days for chief complaint of dental crowding, the patient wanted
the Schwartz appliance. After 14 days, midpalatal to improve her facial esthetics.
suture separation was confirmed by a periapical radio- The patient was rediagnosed with a hyperdivergent
graph. Active expansion was performed for 40 days to Class I skeletal and dental relationship with growth
ensure contact between the palatal cusps of the maxil- potential (Table 1; Figure 5). The arch length defi-
lary posterior teeth and the buccal cusps of the corre- ciencies were 5.5 mm and 2.5 mm in the maxilla and
sponding mandibular teeth, followed by 3 months of mandible, respectively, with normal labiolingual incli-
consolidation and bone formation. nation of the incisors. Residual transverse deficiency
Upon the completion of phase I, dental crowding was with labiolingual inclination compensation of maxillary
successfully reduced in both the upper and lower arches, and mandibular molars was noted (Table 1; Figure 5).
with proper eruption of the second premolars. Compre- The phase II treatment plan included maxillary
hensive treatment was planned after the eruption of the expansion to regain space, followed by retraction of

Figure 7. Force system involving linear horizontal and vertical vectors adjusted during phase II treatment.
the maxillary and mandibular dentition. In addition, to as the one described above for 5 weeks, followed by

eliminate lip incompetency in this hyperdivergent, 6 months of consolidation. Postexpansion cone beam
growing patient, it was imperative to prevent an computed tomography (CBCT) images revealed an
excessive increase in the vertical dimension by active increase in the maxillary intermolar width to 49.3 mm;
vertical control in the bimaxillary dentition.9 Conse- the maxillomandibular transverse differential index
quently, the target movements were posterosuperior (Yonsei transverse index [YTI])10 was noted as 1 mm
displacement of the maxillary dentition and posteroin- (Figure 6A). Next, the maxillary and mandibular arches
ferior displacement of the mandibular dentition. were aligned using a self-ligating bracket system with a
Comprehensive treatment was initiated with the sec- 0.018-inch Roth prescription (Clippy-C, Tomy Inc, Kat-
ond phase of maxillary expansion using the MARPE sushika, Japan) (Figure 6). TSADs (1.8 mm in diameter
appliance. In the maxilla, MARPE was applied using and 7.0 mm in length; Orlus, Ortholution, Seoul, Republic
two TSADs on the anterior and posterior sides of the of Korea) were placed in the buccal interradicular space
jackscrew and was activated using the same protocol between the second premolar and the first molar in each
Figure 8. Posttreatment photographs.


Figure 9. Posttreatment radiographs and cephalometric tracing.
quadrant (Figures 6B and 7). Oblique upward lines of movement while minimizing occlusal plane rotation. Dual
force of 200 g were applied along with stiff 0.016 3 TSADs have been reported to lead to a resultant force
0.022-inch stainless steel working wires for simultaneous vector closer to the center of resistance of the mandibular
bimaxillary total arch intrusion and distalization. The dentition, thus increasing the efficiency of the treatment
amount and direction of the total arch movement and process (Figure 7).13
torque of the anterior teeth were closely monitored and After 43 months of active treatment, anteroposte-
controlled throughout the treatment.11 During active treat- rior movement of the teeth was completed, and the
ment, TSADs were strategically relocated to prevent root finishing stage lasted for 8 months, with intermaxillary
interference while achieving adequate distal tooth move- box elastics in use to seat the occlusion. The appli-
ment.12 In the mandible, bilaterally dual TSADs were later ances and TSADs were removed after 4 years 3
used to enhance force control and optimize total arch months of treatment, and fixed lingual retainers were


Figure 10. Serial CBCT images of the mandibular incisors at the initiation of phase II (A) and posttreatment (B).
delivered in both arches. A maxillary circumferential regarding dental crowding and her facial profile
retainer was delivered with instructions for all-day while significantly eliminating lip incompetence.
wear for the first 6 months, followed by nighttime use The occlusion was appropriately aligned with ade-
thereafter (Figure 8). quate overjet and overbite, and the dental midline was
coincident with the facial midline, resulting in stable
occlusion. At the end of the treatment, no noticeable gin-
Treatment Results
gival recession or tooth mobility was observed; however,
The second phase of nonextraction treatment minor root resorption in the mandibular incisors and first
successfully resolved the patient’s chief complaint molars was noted and monitored (Figures 8 through 10).
Figure 11. Superimposition of the pre– and post–phase II treatment tracings.


Figure 12. Serial CBCT images and three-dimensional reconstruction images taken during phase II treatment. (A) At initiation. (B) During
mandibular tooth distalization. (C) Posttreatment.
Cephalometric analysis and superimposition revealed DISCUSSION

limited vertical growth with a counterclockwise rotation
One of the primary goals of orthodontic treatment is to
of the mandible. Her chin prominence increased signifi-
achieve a harmonious balance between the patient’s
cantly, contributing to the improvement of her facial pro-
facial features and occlusion, which necessitates appro-
file. The maxillary incisor was proclined slightly labially,
priate orthodontic tooth movement. However, anatomical
while the mandibular incisor had a normal labiolingual
limitations, such as the cortical plate of the alveolar bone,
inclination. The mandibular dentition was distalized by
can restrict the extent of tooth movement.3,4 Excessive
5 mm and intruded by 2 mm (Table 1; Figures 8 movement into the cortical bone can have negative con-
through 11). sequences, including bone dehiscence and root resorp-
Posttreatment CBCT revealed stable transverse tion. The occurrence of palatal and lingual alveolar bone
expansion with no obvious adverse effects (Figure 9). dehiscence during the retraction of maxillary and mandib-
Serial CBCT images and three-dimensional reconstruc- ular anterior teeth has been documented by several
tion images taken during phase II treatment revealed sig- authors, and the potential for recovery is debatable.5,14–16
nificant bone remodeling surrounding the mandibular The ability of bone remodeling in the mandibular posterior
molars (Figure 12). During distalization, bone dehiscence lingual cortical plate to facilitate effective total arch distali-
was observed in the lingual alveolar bone of the mandib- zation with minimal adverse effects in a growing patient
ular molars. However, no root exposure or gingival reces- has not been previously reported.
sion was observed (Figure 12B). The images in Figure Previous studies have demonstrated the possibility
12B and C, obtained at an interval of 1 year 9 months, of cortical bone remodeling and bone apposition fol-
exhibit the bone regeneration ability of this growing lowing orthodontic tooth movement.5,6,15,17–19 Some
patient. At the end of the treatment, the lingual surfaces factors are considered favorable for bone regenera-
of the roots were recovered to some extent, with new tion. According to previous studies, the biotype of the
alveolar bone being present (Figure 12C). labiolingual dimension of the gingiva is a significant
At 2 years 4 months after retention, the results morphological factor in determining the protection of
remained stable (Figure 13). The stability of transverse teeth from possible inflammation or trauma caused
expansion was confirmed (intercanine and intermolar by bone dehiscence.5,18–20 Bae et al.5 assumed that
widths at the crown level of 46.9 mm and 58.3 mm in if the gingival biotype was thick and healthy with a
the upper arch and 37.7 mm and 47.8 mm in the lower potential periodontal ligament, regeneration of alveo-
arch, respectively). lar bone could be observed regardless of the degree

Figure 13. Facial and intraoral photographs and dental models obtained at the follow-up visit, 2 years 4 months after retention. Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/94/3/353/3359293/i1945-7103-94-3-353.pdf by guest on 09 August 2024
of tooth movement. Additionally, long-term light-force efficient orthodontic tooth movement by more active
activation and bodily tooth movement were proposed cell proliferation, differentiation, and bone formation
to allow optimal adaptation of the alveolar bone, in younger patients than in adults.18,19 In this patient,
reducing the risk of adverse effects.6,17,21 However, it interim bone dehiscence occurred on the lingual sur-
seems difficult to detect bone regeneration immedi- face of the mandibular molars with minor root resorp-
ately after dehiscence occurs during incisor retraction in the mandibular first molars during total arch
tion, and a recovered root surface with a well-defined distalization. However, significant bone regeneration
cortical plate has been reported several years after around the exposed root surface was observed at the
the termination of active treatment.5 Growth potential end of the treatment, without any tendency toward
can be a favorable factor that can aid in achieving root exposure, gingival recession, or tooth mobility

(Figure 12). The successful adaptation and regenera- REFERENCES

tion of the alveolus surrounding the distal root of the
1. Xu T-M, Liu Y, Yang M-Z, Huang W. Comparison of extrac-
second molars, followed by root movement, were tion versus nonextraction orthodontic treatment outcomes
noted. Eventually, considerable distalization of the for borderline Chinese patients. Am J Orthod Dentofacial
mandibular dentition was successfully achieved with Orthop. 2006;129:672–677.
minimal side effects due to the regeneration potential 2. Choi SH, Jeon JY, Lee KJ, Hwang CJ. Clinical applications
of this growing patient (Figures 8 and 9). Neverthe- of miniscrews that broaden the scope of non-surgical ortho-
less, it must be considered that this type of remodel- dontic treatment. Orthod Craniofac Res. 2021;24:48–58.
ing may be subject to individual response, which may 3. Kim S-J, Choi T-H, Baik H-S, Park Y-C, Lee K-J. Mandibular
posterior anatomic limit for molar distalization. Am J Orthod
be limited in adult patients.17–19,22
Dentofacial Orthop. 2014;146:190–197.
One of the most marked changes in this patient was

4. Hui VLZ, Xie Y, Zhang K, et al. Anatomical limitations and
the increase in chin prominence. Despite the patient’s factors influencing molar distalization. Angle Orthod. 2022;
hyperdivergent growth pattern, simultaneous bimaxillary 92:598–605.
total arch intrusion effectively suppressed vertical dento- 5. Bae S-M, Kim H-J, Kyung H-M. Long-term changes of the
alveolar growth within the basal bone, resulting in the anterior palatal alveolar bone after treatment with bialveolar
redirection of the growth pattern with counterclockwise protrusion, evaluated with computed tomography. Am J
rotation of the mandible and increased chin prominence. Orthod Dentofacial Orthop. 2018;153:108–117.
6. Oh H, Herchold K, Hannon S, et al. Orthodontic tooth move-
Eventually, vertical facial growth was restricted.9,11 Skel-
ment through the maxillary sinus in an adult with multiple miss-
etal growth modification, combined with coincident, nor- ing teeth. Am J Orthod Dentofacial Orthop. 2014;146:493–505.
mal vertical growth of the lip, effectively eliminated lip 7. Antoun JS, Mei L, Gibbs K, Farella M. Effect of orthodontic
incompetence and improved the patient’s facial pro- treatment on the periodontal tissues. Periodontol 2000.
file without performing extractions (Table 1; Figures 8 2017;74:140–157.
through 11). 8. Chun J-H, de Castro ACR, Oh S, et al. Skeletal and alveolar
Active treatment took 4 years 3 months and resulted changes in conventional rapid palatal expansion (RPE) and
in significant improvements in the patient’s dental miniscrew-assisted RPE (MARPE): a prospective random-
ized clinical trial using low-dose CBCT. BMC Oral Health.
crowding, facial esthetics, and occlusion (Figure 8).
2022;22:114.
The age of the patient at treatment completion, 17 years 9. Lee KJ. The application of TADs for gummy smile correc-
for this patient, is considered to be an important factor in tion. In: Park JH, ed. Temporary Anchorage Devices in Clin-
ensuring the long-term stability of the treatment outcome ical Orthodontics. Hoboken, NJ: Wiley; 2020:633–645.
as insignificant growth would be expected thereafter 10. Koo Y-J, Choi S-H, Keum B-T, et al. Maxillomandibular arch
(Figure 9).17 The patient expressed satisfaction with the width differences at estimated centers of resistance: com-
results, and the 2-year 4-month follow-up records con- parison between normal occlusion and skeletal Class III
firmed the stability of the treatment results (Figure 13). malocclusion. Korean J Orthod. 2017;47:167–175.
11. Lee K-J, Kim S-J. Advanced biomechanics for total arch
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becoming unfavorably impacted. 12. Tai K, Park JH, Tatamiya M, Kojima Y. Distal movement of
the mandibular dentition with temporary skeletal anchorage
CONCLUSIONS devices to correct a Class III malocclusion. Am J Orthod
• Gradual bone remodeling in the mandibular posterior 13. Bechtold TE, Kim J-W, Choi T-H, Park Y-C, Lee K-J. Distali-
lingual cortical plate of a growing patient enabled zation pattern of the maxillary arch depending on the number
adequate total arch distalization despite anatomical of orthodontic miniscrews. Angle Orthod. 2013;83:266–273.
limitations. 14. Sarikaya S, Haydar B, Cig er S, Ariyu€rek M. Changes in
• The alveolar bone surrounding the dental roots was alveolar bone thickness due to retraction of anterior teeth.
properly remodeled as an adaptation process, which Am J Orthod Dentofacial Orthop. 2002;122:15–26.
15. Eksriwong T, Thongudomporn U. Alveolar bone response to
consequently resulted in the successful distalization
maxillary incisor retraction using stable skeletal structures
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• The implementation of light-force and strategic- 16. Liu Y, Jiang J, Zhang H, Xu T. Long-term remodeling of
force systems to induce bodily tooth movement, anterior alveolar bone from treatment to retention. Front
along with adequate skeletal growth, could be a crit- Med China. 2009;3:408–414.
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and correction of skeletal Class III malocclusion with gradual
ACKNOWLEDGMENT dentoalveolar remodeling in a growing patient. Am J Orthod
This report was supported by a research grant from the 18. Kim J-W, Baik H-S, Mo S-S, Giap H-V, Lee K-J. Age-related
Seoul Business Agency (BT210124). osteogenesis on lateral force application to rat incisor—part

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osteogenesis on lateral force application to rat incisor—part III: ping of incisors in monkeys. J Periodontol. 1976;47:450–454.
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ment of dehiscences during labial movement of mandibular 2022;12:9161.

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Case Report

Combined distalization and lingual cortex remodeling during mandibular

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/94/3/353/3359293/i1945-7103-94-3-353.pdf by guest on 09 August 2024

INTRODUCTION (TSADs) can be effective and predictable treatment

DOI: 10.2319/060123-390.1 353 Angle Orthodontist, Vol 94, No 3, 2024

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/94/3/353/3359293/i1945-7103-94-3-353.pdf by guest on 09 August 2024

Figure 2. Pretreatment dental models.

Angle Orthodontist, Vol 94, No 3, 2024

Table 1. Cephalometric Analysis Measurementsa

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Figure 3. Pretreatment radiographs and cephalometric tracing.

Angle Orthodontist, Vol 94, No 3, 2024

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Lateral cephalometric analysis revealed a hyperdi- Treatment Objectives

Angle Orthodontist, Vol 94, No 3, 2024

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an improved facial proﬁle. However, challenges Treatment Progress

Angle Orthodontist, Vol 94, No 3, 2024

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Figure 8. Posttreatment photographs.

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Figure 11. Superimposition of the pre– and post–phase II treatment tracings.

Angle Orthodontist, Vol 94, No 3, 2024

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Cephalometric analysis and superimposition revealed DISCUSSION

Angle Orthodontist, Vol 94, No 3, 2024

Angle Orthodontist, Vol 94, No 3, 2024

(Figure 12). The successful adaptation and regenera- REFERENCES

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