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Miniscrew-assisted multidisciplinary orthodontic treatment with surgical

mandibular advancement and genioplasty in a brachyfacial Class II patient
with mandibular asymmetry

Article in American Journal of Orthodontics and Dentofacial Orthopedics · November 2017

DOI: 10.1016/j.ajodo.2016.09.031

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CASE REPORT

Miniscrew-assisted multidisciplinary
orthodontic treatment with surgical
mandibular advancement and
genioplasty in a brachyfacial Class II
patient with mandibular asymmetry

nica Garc
ıa-Sanz, and Carlos Bellot-Arc
ıs
Vanessa Paredes-Gallardo, Vero
Valencia, Spain

This article describes the complex dental treatment of a 43-year-old man with skeletal Class II, mandibular asym-
metry, severe brachyfacial pattern, Class II Division 2, canting of the occlusal plane, and an increased curve of
Spee. To achieve optimal results, we adopted a multidisciplinary approach to treatment, involving periodontics,
oral surgery, orthodontics, maxillofacial surgery, and prosthetics specialists. After periodontal treatment, mini-
screws were placed to correct the occlusal plane canting and the excessive curve of Spee with orthodontic treat-
ment. The surgical treatment plan consisted of a bilateral asymmetric sagittal split osteotomy for mandibular
advancement and genioplasty. The patient had an infection after the surgery at the site of the right fixation plate,
so the plate was removed, and active orthodontic treatment was continued and finished. Mandibular first molar
implants and maxillary ceramic crowns using the Digital Smile Design method (Digital Smile Design, Doral, FL)
were placed at the end of orthodontic treatment. The patient was satisfied with the treatment results and with his
facial and dental appearance, as well as his oral function. The 2-year follow-up pictures show a stable result both
esthetically and functionally. (Am J Orthod Dentofacial Orthop 2017;152:679-92)

D
emand for facial and dental esthetic procedures most cases, the aims of these procedures are not only
by adults is growing. Most of these patients to correct the dental relationship and to harmonize
have more than 1 oral problem: eg, periodontal function but also to improve facial esthetics.1,2
disease, caries, missing teeth, distressed crowns, and Genioplasty is often conducted in combination with
different restorations. Because of these concomitant mandibular advancement when patients have a flat or
issues in many adults seeking orthodontic treatment, insufficient labiomental fold requiring greater chin
the intervention of different specialists (eg, periodontist, projection.2 But in most Class II Division 2 patients
oral and maxillofacial surgeon, prosthodontist, ortho- with severe deep overbite, the chin is overprojected, so
dontist) may be required to ensure esthetic and func- a chin setback osteotomy is often required.3
tional results. Numerous studies have investigated the effects of
The treatment of nongrowing skeletal Class II craniofacial morphology (facial pattern) and skeletal
patients frequently consists of a combination of class on the posterior airway space.4 Some studies have
orthodontic and orthognathic surgical procedures. In shown that bilateral mandibular advancement surgery
in Class II patients leads to significant increases in pos-
terior airway space volume and significant widening of
From the Orthodontics Department, University of Medicine and Dentistry of Va- the narrower sites inside the pharynx.5-8
lencia, Valencia, Spain.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- In addition to a skeletal discrepancy, Class II Division
tential Conflicts of Interest, and none were reported. 2 patients generally have multiple dental issues, such as
Address correspondence to: Vanessa Paredes-Gallardo, Orthodontics Depart- deep overbite due to an increased curve of Spee, retrocli-
ment, University of Medicine and Dentistry of Valencia, C/Gasco Oliag no 1, Va-
lencia 46010, Spain; e-mail, [email protected]. nation of maxillary incisors, and occlusal plane canting.
Submitted, July 2016; revised and accepted, September 2016. Correction of occlusal plane canting can be achieved
0889-5406/$36.00 with conventional orthodontic appliances assisted by
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.09.031 miniscrews, intruding the teeth on the corresponding

679
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Fig 1. Pretreatment facial and intraoral photographs.

side of the dental arch. In some cases, this will avoid Le- approach to treatment involving periodontics, oral sur-
Fort I surgery.9-12 gery, orthodontics, maxillofacial surgery, and prosthetics
Treatment of Class II Division 2 malocclusion, charac- specialists. See Supplemental Materials for a short video
terized by retroclination of the maxillary incisors and presentation about this study.
deep overbite, has been considered challenging because
of the difficulty of controlling the orientation of the DIAGNOSIS AND ETIOLOGY
incisor axis. This makes both the intrusion and the torque A 43-year-old man complained of a poor smile and
control of the retroclined maxillary incisors important facial profile esthetics, referring specifically to the
treatment objectives.13 Miniscrews placed in the interra- marked mentolabial fold and submental fullness. He
dicular areas as anchorage units provide true intrusion of was also concerned about a snoring problem.
the incisors in patients with deep overbite and prevent The frontal photograph shows mandibular asymme-
unwanted movements to the rest of the teeth; this cannot try, with the mandible shifted to the right. Maxillary
be achieved by conventional methods.14,15 incisal exposure during smiling was considered to be
This case report presents a successful orthodontic and within the normal range, with no exposed gingiva. The
orthognathic surgical treatment of an adult with skeletal lateral photograph shows a concave facial profile, with
Class II Division 2 and a severe brachyfacial pattern. To severe reduction of the lower facial third and overpro-
achieve optimal results, we adopted a multidisciplinary jected chin (Fig 1).

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Fig 2. Pretreatment dental casts.

The molar and canine Angle relationships were com- first premolars, and the mandibular first molars had
plete Class II. Overjet and overbite were 7.2 and 8.0 mm, been treated endodontically, as seen in the pano-
respectively. The mandibular dentition showed an exces- ramic radiograph. Periapical lesions were seen in
sive curve of Spee because of the overerupted incisors. In the mandibular first molars that had old single
addition, a canted occlusal plane was present, and the metal-ceramic crowns. The maxillary third molars
maxillary left first premolar had a scissors-bite. The had already been extracted by the oral surgeon,
maxillary dental midline matched the facial midline, whereas the mandibular third molars were still pre-
whereas the mandibular dental midline deviated to the sent (Fig 3, C).
right because of the asymmetry. The discrepancy index Based on these findings, the patient was diagnosed
values were –3 and –4.1 mm for the maxillary and with skeletal and dental Class II Division 2, with excessive
mandibular arches, respectively. There were several old overbite and overjet, increased curve of Spee, and
single metal-ceramic crowns in both arches. An anterior occlusal plane canting. Several teeth had old metal-
Bolton ratio discrepancy was present in the maxillary ceramic crowns and had been treated endodontically.
central and lateral incisors (Figs 1 and 2). Periodontal health and airway space were also compro-
The patient had chronic mild periodontitis with mised.
bleeding of almost every tooth; the papillae between
the maxillary left central and lateral incisor and between TREATMENT OBJECTIVES
the maxillary left lateral incisor and canine were missing
The treatment objectives were (1) to establish a skel-
because of a deficiency in the adjustment of the old sin-
etal and dental Angle Class I relationship, (2) to level the
gle metal-ceramic crowns (Fig 1).
occlusal plane and flatten the curve of Spee to achieve a
The cephalometric analysis (Fig 3, A and B; Table)
harmonious smile, (3) to obtain a balanced facial profile,
showed a skeletal Class II (ANB, 3.3 ) with a severe bra-
(4) to widen the pharyngeal airway space to minimize the
chyfacial pattern (facial axis, 95.4 ; FMA, 6.9 ; lower
snoring problem, and (5) to improve the look and adjust-
facial height, 60.1 mm). The maxillary and mandibular
ment of the restorations for better periodontal health
incisors were lingually inclined (U1- palatal plane,
and a more attractive smile.
99.8 ; IMPA, 92.9 ); as a result, the interincisal angle
was increased (156.3 ). The patient had a narrow middle
and lower pharyngeal airway space (Fig 3, A). TREATMENT ALTERNATIVES
The maxillary left central and lateral incisors, the Both surgical and nonsurgical treatment ap-
maxillary right first and second premolars and left proaches were considered. Nonsurgical treatment or

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

not improve the patient's profile (facial esthetics

Table. Pretreatment and posttreatment cephalo-
was one of the patient's major concern). It would
metric summary
also threaten the periodontal health of the mandib-
Cephalometric analysis Initial Norm Final ular incisors due to excessive proclination, and it
SNA angle ( ) 84.5 82 83 would not widen the pharyngeal airway space, which
SNB angle ( ) 81.2 80 83 was initially compromised. For all these reasons,
ANB angle ( ) 3.3 2 0
orthodontic-orthognathic surgery was planned to
Wits appraisal (mm) 0.5 1 3
U1-palatal plane ( ) 99.8 110 115 fulfill the desired esthetic, functional, and health ob-
IMPA (L1-MP) ( ) 92.9 95 99.3 jectives.
Interincisal angle ( ) 156.3 130 127
Overjet (mm) 7.2 2.5 2.7 TREATMENT PROGRESS
Overbite (mm) 8 2.5 1.8
Facial axis (NABA-PTGN) ( ) 95.4 90 91.5 A treatment plan was developed with a team
FMA (MP-FH) ( ) 6.9 22.9 14.8 approach involving orthodontics, periodontics, oral sur-
Lower facial height (ANS-ME) (mm) 60.1 66.5 67.8 gery, orthognathic surgery, and prosthodontics.
Mandibular length (GO-GN) (mm) 73 83 80.7
The treatment comprised 3 phases. The initial phase
involved preoperative orthodontic treatment with a
dental camouflage consisting of maxillary arch align- preparation time of 10 months. Initially, nonsurgical
ment and occlusal plane leveling, followed by exces- periodontal treatment (scaling and root planing) was
sive labial tipping of the mandibular incisors to performed by the periodontist based on the premise
minimize overjet was rejected because this would that orthodontic treatment can lead to irreversible

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Fig 5. Mechanics for mandibular incisor intrusion using

miniscrews.

alveolar bone at the second quadrant between the

maxillary left lateral incisor and canine to correct
occlusal plane canting (Fig 4), and 2 more were placed
in the mandibular incisor area to obtain intrusion of
Fig 4. Mechanics for occlusal plane canting correction the incisors (Fig 5). Miniscrews were used as direct
using a miniscrew between the maxillary left lateral incisor anchorage units, and force was applied to the archwire
and canine. with an elastic thread. The screws were placed in the mu-
cosa and inserted in the interradicular areas under local
anesthesia at the start of treatment. After 6 months,
breakdown of the periodontium when active periodonti- intrusion of the mandibular anterior teeth was achieved,
tis is present. At the same time, the mandibular third mo- and the canting of the occlusal plane was corrected, so
lars were extracted by the oral surgeon. the miniscrews were removed.
Second, the mandibular left first molar was scheduled After the initial phase, the patient was referred to the
for extraction by the oral surgeon because of signs and orthognathic surgeon for the second phase. A surgical
symptoms including pain and a periapical lesion; the treatment plan and a surgical model were designed ac-
right first molar was maintained in the mouth and cording to the esthetic treatment objectives. It consisted
kept under observation since the patient reported no of a bilateral asymmetric sagittal split osteotomy for
discomfort or pain. The old distressed single metal- mandibular advancement (3.01 and 5.84 mm for the
ceramic crowns were replaced by provisional resin left and right sides, respectively) and also, since down
crowns, so that the condition of the papillae could sliding of the chin was needed, genioplasty
improve. (Fig 6). Rigid fixation was used in the mandible with
A 0.022 3 0.028-in slot preadjusted edgewise appli- plates and miniscrews. Two more miniscrews were
ance (Victory Series; 3M Unitek, Monrovia, Calif) was placed interapically in both jaws for an intermaxillary
placed on the mandibular arch, and a self-ligating elastic. The lower midline and mandibular asymmetry
0.022 3 0.028-in slot appliance system (Clarity; 3M improved significantly after this surgical procedure.
Unitek) was used on the maxillary arch. MBT prescrip- Four weeks after surgery, the miniscrews were
tions were chosen for the appliances in both arches. Or- removed, and the patient was referred back to the ortho-
thodontic alignment and leveling were achieved using dontist to begin postsurgical orthodontic treatment (third
nickel-titanium 0.014-in, 0.016-in, 0.019 3 0.025-in, treatment phase). At this time, the patient had an infec-
and 0.021 3 0.025-in archwires, whereas stainless steel tion, diagnosed on the basis of wound dehiscence, gran-
0.016-in, 0.019 3 0.025-in, and 0.021 3 0.025-in arch- ulation tissue, and pus at the site of the right fixation
wires were used to correct the dental arches. Additional plate. He was prescribed oral antibiotics to control the
torque to the maxillary incisors was necessary, so Warren infection, and 6 weeks after surgery the right plate were
torquing springs (Rocky Mountain Orthodontics, Den- removed, and active orthodontic treatment was stopped.
ver, Colo) were used in combination with the stainless Four weeks later, postoperative orthodontic treat-
steel 0.021 3 0.025-in archwires. ment recommenced for a further 6 months until an
One miniscrew (length, 10 mm; diameter, 1.6 mm; optimal occlusion was obtained. Short triangular inter-
Jeil Medical, Seoul, Korea) was inserted into the buccal maxillary 1/8-in elastics (Super Thread; Rocky Mountain

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Fig 6. Surgical treatment plan and surgical model.

Orthodontics) were used to obtain premolar interdigita- The posttreatment pictures and casts illustrate good
tion. The orthodontic appliances were removed after interdigitation of the teeth. In addition, an Angle Class
that. I molar relationship and an acceptable interincisal rela-
The total duration of the orthodontic treatment was tionship had been established. All papillae recovered,
approximately 18 months. Mandibular first molar im- especially those between the maxillary left central
plants and maxillary ceramic crowns were placed at incisor, left lateral incisor, and left canine thanks to
this time. The esthetic rehabilitation to replace the old the perfect marginal adaptation of the ceramic crowns
crowns used the Digital Smile Design (Digital Smile (Figs 7 and 8).
Design, Doral, FL) method to assist treatment through The cephalometric analysis also showed significant
an esthetic analysis of the face, smile, periodontal tissue, changes to the patient's measurements (Fig 9, A and B;
and teeth with the Cerec Cad/Cam System (VITA Zahn- Table). The ANB angle decreased from 3.3 to 0 . The
fabrik, Bad S€ackingen, Germany). maxillary and mandibular incisors were buccally inclined.
Retention included fixed canine-to-canine lingual Facial pattern measurements changed significantly (facial
retainers in both arches, and a maxillary circumferential axis from 95.4 to 91.5 ; FMA from 6.9 to 14.8 ; lower
Hawley retainer to be worn at night. facial height from 60.1 to 67.8 mm). Mandibular length
increased significantly from 73 to 80.7 mm.
TREATMENT RESULTS Acceptable root parallelism was achieved, and neither
Thanks to the use of 2 types of miniscrew mechanics root resorption nor marginal bone loss in the periodontal
(1 for the occlusal plane canting, and the other for the tissues was observed (Fig 9, C).
incisor intrusion to flatten the excessive curve of Spee), The chronic mild periodontitis improved as shown in
the patient's orthodontic problems improved, and the the initial (Fig 10, A) and final (Fig 10, B) periodonto-
presurgical orthodontic treatment time was significantly grams; there was no bleeding at the end of treatment.
shortened. After the mandibular advancement surgery, the to-
An acceptable occlusion and a satisfactory facial pro- tal volume of the pharyngeal airway space increased
file were also obtained. The posttreatment facial photo- from 10.0 to 14.5 cm3, and the area improved from
graphs showed a balanced and harmonious face (Fig 7). 86.3 to 178.6 mm2 as can be observed by comparing
The patient was satisfied with the treatment results. the initial (Fig 11, A) and final cone-beam computed

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Fig 7. Posttreatment facial and intraoral photographs.

tomography images (Fig 11, B). The patient's snoring Figure 16 shows the superimposition of the pretreat-
ceased. ment, posttreatment, and postretention cephalometric
After a 24-month retention period, the facial es- tracings, illustrating the dental, skeletal, and soft tissue
thetics and occlusion achieved at the end of treatment changes achieved as the result of treatment and the sta-
had been perfectly maintained (Figs 12 and 13). bility in the postretention period.
In the comparison of the pretreatment (Fig 14, A and
B), posttreatment (Fig 14, C and D), and postretention
(Fig 14, E and F) dental casts, it can be observed that, DISCUSSION
at the end of treatment, the overerupted mandibular in- There is little doubt that good treatment outcomes
cisors were significantly corrected and intruded, and the in an adult patient with multiple dental issues in addi-
excessive curve of Spee was also flattened; these re- tion to a severe skeletal discrepancy and severe bra-
mained stable after the 2-year retention period. chyfacial pattern will require a multidisciplinary
The postretention cephalometric analysis (Fig 15, A approach. This patient had additional oral problems:
and B) showed no changes in comparison with the mild periodontal disease, distressed crowns, and peri-
posttreatment analysis (Fig 9, A and B). The postreten- apical lesions. In this situation, the orthodontist plays
tion panoramic radiograph showed no changes either a determining role by coordinating the orthodontic
(Fig 15, C) compared with the posttreatment analysis therapy in relation to the other treatments that will
(Fig 9, C). be conducted by the corresponding specialists; this

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Fig 8. Posttreatment dental casts.

will require constant communication between all overjet and overbite remained stable also. Asymmetric
parties. surgical mandibular advancement was not sufficient to
Orthodontic preparation is a time-consuming pro- correct the overall mandibular length, so the mandibular
cess with an average duration of 17 months, ranging advancement was complemented with genioplasty,
from 7 to 47 months.16 In our patient, preoperative which placed the chin in a more forward and downward
treatment took only 11 months, thanks to the use of position, at the same time improving the mentolabial
miniscrews as auxiliary elements. fold.
Orthognathic surgery is not without risks, since some Snoring is a common complaint, affecting many
patients require reoperation to remove fixation plates adults, with men twice as likely to snore as women.
due to symptoms such as pain or infection. Standard These subjects may complain that their sleep is unre-
plates are made of titanium, which is renowned for its freshing and that they feel tired during the day. Patients
strength and biocompatibility. But the insertion of tita- may just be “simple snorers” or may have obstructive
nium in a nonsterile field can lead to complications such sleep apnea.20 In our patient, pharyngeal airway space
as plate infection or failure. According to some authors, was compromised before treatment, as may be observed
the plate removal rate can be up to 15%.17-19 in cone-beam computed tomography images (Fig 11, A).
Our patient suffered an infection at the site of the The snoring problem, which was one of the patient's
right fixation plate, which may have been related to concerns, was attributed to the narrow middle and lower
the mandibular right first molar periapical lesion. After pharyngeal width. Several studies have assessed the as-
a course of antibiotics and a 6-week delay, the plate sociation between airway space and the anteroposterior
was removed according to the recommendations of the jaw relationship and vertical pattern.4 In this patient, the
orthognathic surgeon (based on reports of similar pharyngeal airway space volume increased from 10 to
cases).17-19 14.5 cm3 as a result of mandibular advancement surgery
The patient's mandible was stable, and the mandib- (Fig 11, B), an outcome that concurs with other
ular relationship with the base of the skull (SNB) and research.5-8
the maxillomandibular (ANB) values did not change A deep overbite is a complex orthodontic problem
from the end of treatment to the 2-year postretention that must be corrected at the start of treatment. This pa-
follow-up. The maxillary and mandibular incisors also tient had a Class II with a deep overbite; however, maxil-
maintained their vertical and sagittal positions, and lary incisal exposure during smiling was considered to be

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Fig 9. A, Posttreatment lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.

Fig 10. A, Initial and B, final periodontograms.

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Fig 11. A, Initial and B, final volume and area of posterior airway space.

Fig 12. Postretention facial and intraoral photographs.

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Fig 13. Postretention dental casts.

Fig 14. Comparisons of the curve of Spee in dentals casts (lateral and frontal views): A and B, pretreat-
ment; C and D, posttreatment; E and F, postretention.

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Fig 15. A, Postretention lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.

within the normal range and did not show any gingiva. the miniscrew group, but no signs of root shortening
Additionally, the mandibular dentition had an excessive were observed.
curve of Spee because of the patient's overerupted inci- Miniscrews were also used to correct the maxillary
sors. Therefore, intrusion of the mandibular incisors was occlusal plane canting, achieving satisfactory outcomes.
considered to be the only option for improving the Some authors have concluded that for mild occlusal
excessive overbite and preventing flattening of the smile plane canting in patients without severe facial asymme-
arch, which would have worsened smile esthetics. Mini- try, intrusion of the extruded maxillary quadrant using
screws and light forces (5-15 g per tooth) were applied to miniscrews is an efficient, predictable, quick, and less-
intrude the incisors; the force's line of action passed invasive alternative therapy.9-12
close to and posterior to the center of resistance result- Both maxillary and mandibular incisors were
ing in a straight intrusion (Fig 17, B) without labial lingually inclined before treatment. Preadjusted appli-
tipping of the incisors, which could have occurred had ances were insufficient to correct the maxillary incisor
the line of action been anterior to the center of resistance torque, and so to obtain better esthetics and sufficient
(Fig 17, A).21 overjet to allow the desired mandibular advancement,
The application of direct intrusion forces by means of Warren springs torque devices (Rocky Mountain Ortho-
miniscrews offers an efficient treatment option. As well dontics) were used. They proved to be an efficient
as being an effective method of intrusion, it prevents method for applying torque to the incisors.23 In this
the reciprocal movement of other teeth, unlike other op- case report, these auxiliary torque devices were used to
tions such as utility arches.22 The most important draw- achieve an ideal inclination.
back of intrusion mechanics is root resorption. Periapical Lastly, significant improvement to the relationship
radiographs were taken of the 4 mandibular incisors in between the gingival margins and teeth (papillae) was

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Fig 16. 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 men-
ton.

Fig 17. Mechanics for mandibular incisor intrusion with miniscrews: A, intrusion force applied anterior
to the center of resistance, resulting in labial tipping of the incisors; B, intrusion force applied more pos-
teriorly passing through the center of resistance, resulting in straight intrusion.

achieved at the end of orthodontic therapy after the treatment planning and cooperation between the
placement of new and properly adapted ceramic crowns. different specialists led by the orthodontist were essen-
tial to the success of the final outcome: a functional oc-
CONCLUSIONS clusion and satisfactory facial esthetics, which met the
Multidisciplinary management, involving periodon- patient's expectations.
tics, orthodontics, orthognathic and oral surgery, im-
plants, and prosthetics, was required to treat a ACKNOWLEDGMENTS
43-year-old man with a skeletal Class II and a severe bra-
chyfacial pattern, mild chronic periodontitis, and a Class We thank Alfonso Borja (orthognathic surgeon),
II Division 2 dental malocclusion with canting of the Vicente Berbis (prosthodontist), and Fernando Albalat
occlusal plane and an increased curve of Spee. Careful (periodontist).

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SUPPLEMENTARY DATA 10. Jeon YJ, Kim YH, Son WS, Hans MG. Correction of a canted
occlusal plane with miniscrews in a patient with facial asymmetry.
Supplementary data related to this article can be Am J Orthod Dentofacial Orthop 2006;130:244-52.
found online at http://dx.doi.org/10.1016/j.ajodo. 11. Ko DI, Lim SH, Kim KW. Treatment of occlusal plane canting using
2016.09.031. miniscrew anchorage. World J Orthod 2006;7:269-78.
12. Komori R, Deguchi T, Tomizuka R, Takano-Yamamoto T. The use
of miniscrew as orthodontic anchorage in correction of maxillary
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November 2017  Vol 152  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
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