IP Indian Journal of Orthodontics and Dentofacial Research 2021;7(4):323–326

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IP Indian Journal of Orthodontics and Dentofacial Research

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Case Report
Orthodontic management of skeletal Class II malocclusion using three
mini-implants- A case report
Shahanamol V P1, *, Vincy Antony1 , Gazanafer Roshan1 , Junaid Ali1
1 Dept. of Orthodontics and Dentofacial Orthopedics, MES Dental College, Perinthalmanna, Kerala, India

ARTICLE INFO ABSTRACT

Article history: Vertical dimension issues are frequently regarded as the most difficult dentofacial problems to treat in
Received 17-12-2021 clinical practice. The difficulty level increases when vertical dysplasia is paired with sagittal discrepancy.
Accepted 20-12-2021 The use of mini-implants in Orthodontics has broadened the scope of orthodontic treatment options. The
Available online 24-01-2021 treatment of a 14-year-old female patient with skeletal Class II malocclusion, slight hyperdivergent profile,
and enhanced incisor visibility with four premolar extraction followed by comprehensive orthodontic
treatment to correct the convex profile and increased incisor visibility, with two posterior implants for
Keywords: retraction and a midline mini implant for intrusion of the anterior maxillary dentoalveolar segment is
Vertical dysplasia
described in this case report. The active therapy period was 25 months long.
Mini-implants
Hyperdivergent This is an Open Access (OA) journal, and articles are distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon
the work non-commercially, as long as appropriate credit is given and the new creations are licensed under
the identical terms.
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1. Introduction 2. Case Report

Excessive visibility of upper incisors and excessive gingiva The female patient, 14-years of age, reported to the
display on smiling are symptoms of maxillary vertical Department with the presenting complaint of forwardly
excess, which might be skeletal or dentoalveolar in nature placed and excessively visible upper front teeth. The
(gummy smile). 1 Skeletal Class II malocclusion is treated by patient had no significant medical or dental history. Upon
growth modification in developing patients and camouflage facial examination, the patient presented with a convex
in adults if the skeletal discrepancy is mild to moderate. The profile, incompetent lips with increased incisor visibility
severity of the sagittal disparity, especially when it coexists and deficient chin (Figure 1). Intraoral examination revealed
with maxillary vertical excess, enhances the therapeutic Class II end-on molar relation on both sides and end-on
complexity. 2 The skeletal anchorage system, on the other canine relation on the left side. There was increased incisor
hand, has broadened the scope of Orthodontics and is also visibility of more than 4mm at rest. Single tooth scissor
accepted by patients. 3,4 bite was present in relation to the upper right first premolar
(Figure 1).
The following case is a moderate skeletal Class II
malocclusion with both sagittal and vertical maxillary Panoramic radiograph revealed all erupted permanent
excess which was treated with mini-implants to achieve teeth except the third molars (Figure 2) with adequate
better facial and smile esthetics. alveolar bone and normal root morphology. Occlusal radio-
opacities can be seen in 36 and 46 indicating restorations.
Lateral cephalometric analysis showed a skeletal Class
* Corresponding author. II malocclusion with convex profile, prognathic maxilla and
E-mail address: [email protected] (Shahanamol V P). normal mandible, proclined upper and lower incisors and

https://doi.org/10.18231/j.ijodr.2021.053
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potentially incompetent lips (Table 1). for intrusion of the maxillary anterior segment to correct the
Model analysis revealed a Bolton’s ratio showing excess excessive incisor display. Two Mini-implants of 1.4mm x
of maxillary overall and anterior tooth material. 8mm were inserted between maxillary second premolar and
first molar bilaterally and angulated at 70◦ for retraction
Table 1: of the protruded maxillary anterior segment. Transpalatal
Measurement Pre Post and lingual arches were given in conjunction with TADs to
treatment treatment control the molars.
Anteroposterior Skeletal
SNA 87o 83o 2.4. Treatment progress
SNB 79o 79o
ANB 8o 4o The patient was treated using Ormco Mini 2000 brackets
Vertical Skeletal 0.022′′ × 0.028′′ MBT prescription. Treatment was started
GoMe- FHP 29o 27o with extraction of upper first premolars and lower second
FMA 28o 26o premolars. The first molars were banded with soldered
ANS-Me 52mm 50mm transpalatal arch and lingual arch and cemented in place.
Dental This was followed by bracket placement in the maxillary
Overjet 5mm 2mm and mandibular arches. Upper and lower 0.016′′ NiTi wires
Overbite 3mm 2mm
were engaged for initial leveling and alignment. Subsequent
U1/SN 125o 113o
to this maxillary and mandibular 0.017′′ × 0.025′′ and
IMPA 109o 98o
0.019′′ × 0.025′′ NiTi wires were placed. This was followed
U1-NF 32mm 30mm
U6-NF 27.5mm 26mm by maxillary and mandibular 0.019′′ × 0.025′′ SS wires
L1-MP 33mm 32mm with brass hooks soldered distal to the lateral incisor
L6-MP 20mm 20mm (Figure 3).
Interlabial gap 5mm 1mm Mini implants of 1.4 mm × 8 mm were inserted
in the maxillary midline lateral to the frenum and also
interdentally between maxillary second premolar and first
molar bilaterally. Retraction was started with active tie
2.1. Diagnosis backs in both upper and lower arches and took about
The patient was diagnosed with Angle’s Class II Division 10months. Finishing and detailing was done with 0.016′′
1 malocclusion on a Class II skeletal base with vertical NiTi followed by 0.017′′ × 0.025′′ NiTi wire. The entire
maxillary excess, upper & lower anterior proclination and treatment period lasted around 25 months.
crowding, scissor bite in relation to 14 with lower midline
shifted towards left by 2mm.

2.2. Treatment objectives

1. Correction of smile esthetics
2. Correction of facial profile
3. Obtaining a harmonious occlusion

This was planned to be achieved by:

1. Reducing the vertical dimension to improve facial

esthetics
2. Correcting the incisor proclination to improve the
profile
3. Correct vertical incisor position to create an esthetic
smile
4. Achieve soft tissue balance and harmony Fig. 1: Pre treatment extraoral and intraoral photographs

2.3. Treatment plan

2.5. Treatment results
As a part of the treatment plan it was decided to extract
upper first premolars and lower second premolars. Three At the end of treatment, the patient’s smile aesthetics and
mini-implants were placed. A Midline mini-implant was facial balance improved, and the lower anterior facial height
placed close to the labial frenum high up in the vestibule was reduced by 2 mm. The lips and chin appeared more
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Fig. 2: Pre treatment Lateral cephalogram and OPG

Fig. 5: Post treatment Lateral cephalogram and OPG

Fig. 3: Retraction with 0.019x0.025” SS with soldered brass

hooks. Implants can be seen in the midline and in the posterior
region

Fig. 6: Cephalometric Superimposition

Pre-treatment and Post-treatmentcephalometric values

dentition and posterosuperior movement of upper incisors

and mandibular counterclockwise rotation. Lower molar
showed favourable anteroposterior change and minimal
vertical change (Figure 6 ).
The post treatment panoramic radiograph showed overall
parallelism of roots. No significant root resorption was
noted (Figure 5).
Fig. 4: Post treatment extraoral and intraoral photographs
3. Discussion
A gummy smile can be caused by vertical maxillary excess,
esthetic (Figure 4). Mandibular plane angle decreased by 2◦ significant gingival overgrowth, altered passive eruption,
(Table 1). anatomically short upper lip, hyper mobile upper lip
Post-treatment cephalometric values showed a decrease muscles, or a combination of these factors. 5–7 Orthodontic
in SNA angle of 4o . This was most likely due to decrease mini-implants have altered orthodontic anchoring and
in proclination of upper anteriors. The overjet reduced by biomechanics by making anchorage completely stable. 8
4mm. Intrusion of upper anteriors occurred by 2mm and Since Creekmore and Eklund reported utilizing a metal
upper molars by 1.5mm resulting in an overall LAFH implant to remedy a deep over bite in 1983, mini-implants
reduction by 2mm. Superimposition of cephalometric have been utilized to intrude incisors. Mini-implants are
tracings showed superior movement of the maxillary commonly utilized nowadays for anterior intrusion and
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retraction to treat deep bite and vertical maxillary excess. 7. Conflicts of Interest
Our patient was a skeletal Class II patient with ANB of
There are no conflicts of interest.
8◦ and proclined and vertically excess maxillary anteriors
with increased incisor visibility. The molar relation was end-
on but the canine relation was Class I on right side. Space References
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Author biography
5. Declaration of Patient Consent
Shahanamol V P, Post Graduate Student
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have Vincy Antony, HOD
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The Gazanafer Roshan, Reader
patients understand that their names and initials will not
Junaid Ali, Former Post Graduate Student
be published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Cite this article: Shahanamol V P, Antony V, Roshan G, Ali J.
6. Source of Funding Orthodontic management of skeletal Class II malocclusion using three
mini-implants- A case report. IP Indian J Orthod Dentofacial Res
No source of funding 2021;7(4):323-326.