CASE REPORT

Nonsurgical correction of a Class III malocclusion

in an adult by miniscrew-assisted mandibular
dentition distalization
Yan Jing,a Xianglong Han,b Yongwen Guo,a Jingyu Li,c and Ding Baid
Chengdu, Sichuan, China

This article reports the successful use of miniscrews in the mandible to treat a 20-year-old Mongolian woman
with a chief complaint of anterior crossbite. The patient had a skeletal Class III malocclusion with a mildly pro-
trusive mandible, an anterior crossbite, and a deviated midline. In light of the advantages for reconstruction of
the occlusal plane and distal en-masse movement of the mandibular arch, we used a multiloop edgewise arch-
wire in the initial stage. However, the maxillary incisors were in excessive labioversion accompanied by little re-
traction of the mandibular incisors; these results were obviously not satisfying after 4 months of multiloop
edgewise archwire treatment. Two miniscrews were subsequently implanted vertically in the external oblique
ridge areas of the bilateral mandibular ramus as skeletal anchorage for en-masse distalization of the mandibular
dentition. During treatment, the mandibular anterior teeth were retracted about 4.0 mm without negative lingual
inclinations. The movement of the mandibular rst molar was almost bodily translation. The maxillary incisors
maintained good inclinations by rotating their brackets 180 along with the outstanding performance of the
beta-titanium wire. The patient received a harmonious facial balance, an attractive smile, and ideal occlusal
relationships. The outcome was stable after 1 year of retention. Our results suggest that the application of
miniscrews in the posterior area of the mandible is an effective approach for Class III camouage treatment.
This technique requires minimal compliance and is particularly useful for correcting Class III patients with
mild mandibular protrusion and minor crowding. (Am J Orthod Dentofacial Orthop 2013;143:877-87)

S
mile attractiveness has been regarded as a stan-
dard of successful treatment by both orthodon-
tists and patients. Evaluating the face in the
smiling prole is also a critical part of a complete
orthodontic diagnosis.1 Maxillary incisors play an
important role in dening beauty, and thus they should
be angulated and positioned most favorably in their
anteroposterior and vertical relationships to all facial
structures to ensure maximum facial harmony.1-4
From State Key Laboratory of Oral Diseases, Department of Orthodontics,
West China Hospital of Stomatology, Sichuan University, Chengdu,
Sichuan, China.
a
Postgraduate student.
b
Associate professor.
c
Postgraduate student.
d
Professor and chair.
The authors report no commercial, proprietary, or nancial interest in the
products or companies described in this article.
Reprint requests to: Ding Bai, State Key Laboratory of Oral Diseases, Department
of Orthodontics, West China Hospital of Stomatology, Sichuan University, 14#,
3rd section of Renmin South Road, Chengdu, Sichuan, China, 610041; e-mail,
baiding@scu.edu.cn.
Submitted, revised and accepted, May 2012.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2012.05.021
Excessive labioversion of the maxillary incisors can
easily ruin a pleasing smile.
Dentoalveolar compensations (proclined maxillary
incisors and retroclined mandibular incisors) are
common in patients with a Class III malocclusion caused
by a retrognathic maxilla or a prognathic mandible.5-8
Also, moderate proclination of the maxillary incisors is
indispensable in camouage treatment of anterior
crossbite. It is always, therefore, challenging for ortho-
dontists to place the maxillary incisors in an appro-
priate anteroposterior position with a harmonious
labial inclination in Class III treatment. To prevent
excessive proclination of the maxillary incisors, distal
en-masse movement of the mandibular dentition is
quite effective in camouage treatment for patients
with a Class III malocclusion.9 The multiloop edgewise
archwire is considered a practical method with fewer
side effects.9-12 However, the extent of occlusal
enhancement that occurs in response to the multiloop
edgewise archwire greatly depends on a patient's
compliance and can vary with each person. As skeletal
anchorage, the application of miniscrews, which offer
more simple and stable force systems, has gradually
become popular and reliable.13-18
877
878 Jing et al

Fig 1. Pretreatment photographs.

Fig 2. Pretreatment study casts.

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Jing et al 879

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

edgewise archwire technique resulted in an unsatisfy-

Table. Cephalometric measurements
ing smile because of the excessive proclination of the
After 4 months of maxillary incisors. Then we stopped to vertically im-
multiloop edgewise plant a pair of miniscrews in the external oblique ridge
Measurement Pretreatment archwire treatment Posttreatment
areas of the bilateral mandibular ramus as anchorage
SNA ( ) 79.1 77.8 77.6
SNB ( ) 81.7 79.2 79.1 for the distal en-masse movement of the mandibular
ANB ( ) 2.6 1.4 1.5 dentition and obtained an excellent treatment outcome
SN-GoGn ( ) 36.1 39.0 38.9 ultimately.
S-Go/N-Me (%) 61.3 59.4 59.4
FH-OP ( ) 9.9 8.7 6.6
U1-SN ( ) 79.6 64.7 77.7 DIAGNOSIS AND ETIOLOGY
L1-NB ( ) 18.4 24.0 13.5 The patient was a 20-year-old Mongolian woman
who had a Class III facial type and slight crowding with
In this case report, we introduce a nonsurgical treat- a complete Class III relationship. Her chief complaint
ment of an adult with a Class III malocclusion with was an anterior crossbite. Her medical history showed
miniscrew-assisted mandibular dentition distalization. no contraindication for orthodontic therapy, and no
At the beginning of the therapy, the multiloop one in her direct family had skeletal Class III features.

American Journal of Orthodontics and Dentofacial Orthopedics June 2013  Vol 143  Issue 6
880
Fig 4. Treatment progress: A, short Class III elastics on multiloop edgewise archwire; B, nickel-
titanium closed coil springs on miniscrews for distal en-masse movement of the mandibular arch.
The photographs taken before treatment showed
symmetric facial structures (Fig 1). The patient had a con-
cave facial prole, a protrusive lower lip, and an acute
nasolabial angle. Her maxillary anterior teeth were
retrognathic, with inadequate display when smiling.
The mandibular dental midline was deviated 2.0 mm to
the right, although the maxillary dental midline was
coincident with the facial midline. There were no signs
or symptoms of temporomandibular joint dysfunction.
Mandibular movements, such as maximal opening and
lateral and anterior displacement, were within normal
limits. No deviation and pain were discovered during
the border movement of the mandible. The dental casts
(Fig 2) showed a Class III occlusion on each side, without
apparent crowding. Overjet was 2.0 mm, and overbite
was 4.5 mm. A cephalogram (Fig 3, A) and a panoramic
radiograph (Fig 3, B) were taken before treatment. The
cephalometric analysis (Table) and its tracing (Fig 3, C)
showed that the mandible protruded relative to the
cranial base (SNB angle, 81.7 ; ANB angle, 2.6 ). The
panoramic radiograph (Fig 3, B) showed no other
abnormal signs, except that the 2 germs of the mandib-
ular third molars were tipped mesially.
After the analysis of the photographs, casts, and
radiographs, it was decided to approach her problems
as a skeletal Class III malocclusion with an anterior
crossbite and a deviated midline.
TREATMENT OBJECTIVES
The treatment objectives were to (1) obtain
a harmonious facial prole by decreasing the protrusion
June 2013  Vol 143  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Jing et al
of the mandible; (2) improve the occlusion, including
correction of the anterior crossbite, establishment of
ideal overjet and overbite, and achievement of Class I
molar relationships; and (3) place the dental midlines
in the middle of the patient's face.
TREATMENT ALTERNATIVES
The rst alternative was combined surgical and
orthodontic treatment. The anterior crossbite would be
corrected with a mandibular setback, and the concave
prole would be improved as well. However, we decided
that her skeletal problem was not sufciently excessive
to require orthognathic surgery.
The second alternative was orthodontic treatment
with extraction of 4 premolars. Through the retraction
of the mandibular anterior teeth and the mesial
movement of the maxillary molars, the anterior crossbite
and Class III molar relationships would be corrected, and
the concave facial prole would be camouaged.
Nevertheless, her mandibular incisors were not suitable
for much distal movement because of the thin trabecular
bone in the mandibular anterior area that could damage
the periodontal tissues by gingival recession, fenestra-
tion, or dehiscence.
The third alternative was to extract the mandibular
third molars and use the multiloop edgewise archwire
technique to obtain distal en-masse movement of the
mandibular arch with short Class III elastics. Thereby,
the anterior crossbite would be corrected, the molar
relationships would be changed into Class I, and her
concave facial prole would be camouaged as well.
Jing et al 881

Fig 5. A and B, Photographs after 4 months of multiloop edgewise archwire treatment; C, cephalogram
after 4 months of multiloop edgewise archwire treatment; D, superimposed cephalometric tracings be-
fore treatment and after 4 months of multiloop edgewise archwire treatment.

After we discussed the 3 alternatives with the patient,
she chose the third option and promised to cooperate in ex-
tracting the third molars and wearing the Class III elastics.
TREATMENT PROGRESS
Orthodontic treatment began on November 9, 2007.
The mandibular third molars were extracted before
bonding. Preadjusted 0.022-in brackets (Shiye, Hang-
zhou, China) were bonded to all teeth. Alignment and
leveling with sequential nickel-titanium archwires were
achieved in 12 months, ending with 0.018 3 0.025-in
stainless steel wires. After that, 0.018 3 0.025-in
stainless steel multiloop edgewise archwires with
progressive tip-back bends were placed in both arches.

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882
Fig 6. A, Frontal x-ray showing the positions of the miniscrews in the mandible; B and C, the positions
of the miniscrews in the oral cavity.
The patient was instructed to wear the short Class III
elastics (3/16 in, 6 oz; 3M Unitek, Monrovia, Calif) for
24 hours per day (Fig 4, A).
The anterior crossbite was corrected substantially
4 months later. However, the maxillary incisors were
proclined remarkably. Class I molar relationships were
not completely established, although the overall
occlusion was improved signicantly. Thus, in the
17th month, we took a set of photos (Fig 5, A and
B) and a cephalogram (Fig 5, C), and made a cephalo-
metric analysis (Table) to reestimate her treatment. The
superimposition of the cephalograms (Fig 5, D)
showed that the correction of the anterior crossbite
was mostly because of the proclined maxillary incisors
without obvious distal movement of the mandibular
incisors. Also, the excessively proclined maxillary
anterior teeth made her facial prole worse, especially
when smiling.
To reinforce the distal en-masse movement of the
mandibular dentition, we modied the treatment plan.
We replaced the orthodontic appliance with 0.022-in
Damon III self-ligating brackets (Sybron Dental Special-
ties Ormco, Orange, Calif) and used miniscrews instead
of the multiloop edgewise archwire technique. When
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Jing et al
rebonding, the maxillary incisor brackets were rotated
180 , assisting in labial root torque at the rectangular
wire stage. The miniscrews were implanted vertically in
the external oblique ridge areas of the bilateral mandib-
ular ramus between the mandibular rst and second
molars, where the greatest thickness of buccolingual
bone was found (Fig 6).19
After 3 months of releveling, we started to draw the
mandibular dentition distally using nickel-titanium
coil springs with 300-g forces on each side. The spring
was connected from the miniscrew to the hook
between the mandibular canine and the rst premolar.
At the same time, 0.019 3 0.025 beta-titanium alloy
wire was used to control the root position of the
maxillary incisors. Six months later, the anterior
overbite and overjet were improved remarkably, and
the labial inclination of maxillary teeth was also
much better (Fig 4, B).
The total treatment duration was 32 months. The
multiloop edgewise archwire technique was used for
4 months, and it took 12 months for the distal
en-masse movement of the mandibular dentition with
miniscrews. The miniscrews were stable all the time
and removed under topical anesthesia.
Jing et al
Fig 7. A and B, Posttreatment photographs; C, photographs after 1 year of retention.
TREATMENT RESULTS
A harmonious facial balance, a charming smile, and
a well-aligned dentition were obtained (Fig 7). The
anterior crossbite was corrected, and Class I molar
relationships were achieved (Fig 8). The posttreatment
cephalogram and panoramic radiograph are shown in
Figure 9. The cephalometric analysis (Table) and the
superimposition (Fig 9, C) show that the ANB angle
increased from 2.6 to 1.5 , and the SNB angle
decreased from 81.7 to 79.1 . According to the
superimposition, the mandibular anterior teeth were
retracted about 4 mm without negative lingual inclina-
tions. The movement of the mandibular rst molar could
be considered almost bodily translation because its
crown was moved 4.0 mm distally, and its roots were
moved 3.0 mm distally. The maxillary incisors were
moved labially under control with good inclination
American Journal of Orthodontics and Dentofacial Orthopedics
883
(U1-SN, 77.7 ). The SN-GoGn angle increased from
36.1 to 38.9 , and S-Go/N-Me decreased from 61.3%
to 59.4%, indicating that the mandible had rotated
clockwise slightly. The patient was satised with the
treatment results, and the outcome was stable after
1 year of retention (Fig 7, C).
DISCUSSION
For this patient, the etiology of her Class III malocclu-
sion was expressed through mandibular protrusion. The
changes contributing most to the correction of her initial
dental and skeletal discrepancies were dentoalveolar
compensation with distal en-masse movement of the
mandibular dentition: a combination of clockwise
rotation of the mandible and counterclockwise rotation
of the occlusal plane. Ideal overjet and overbite
were achieved with controlled labial movement of the
June 2013  Vol 143  Issue 6
884
Fig 8. Posttreatment study casts.
maxillary incisors and retraction of the mandibular
anterior teeth.
The anteroposterior position of the maxillary incisors
is important for the harmony of the face and the beauty
of the smile. To standardize the orthodontic esthetic
analysis, Andrews and Andrews20 noted the 6 elements
of orofacial harmony, for which the patient's forehead
is used as a stable landmark to determine the anteropos-
terior position of the maxillary incisors in the smiling
prole. The facial axis point of the maxillary central
incisors should touch the goal anterior limit line, when
the teeth in each arch conform to element I (ie, arch
shapes and lengths are optimal).20 Either in front of or
behind the goal anterior limit line is not a favorable
anteroposterior position for the maxillary central
incisors. However, the labial inclination of maxillary
incisors can vary and have remarkably different effects
on facial esthetics, even if the facial axis point touches
the goal anterior limit line and the anterior teeth have
good overbite and overjet. Furthermore, the maxillary
incisors can hardly be placed in a standard position for
Class II or Class III camouage treatment because of
the skeletal discrepancy. Consequently, more or less
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Jing et al
inclination of the maxillary incisors is inevitable; this
can greatly impact the static and dynamic beauty of
the facial prole. Previously, we found that the maxillary
incisor that is upright or in a slight lingual inclination is
preferable.21 Labioversion of the maxillary incisors can
easily ruin a pleasing smile, especially for a patient
with a Class III facial type.2,21 Thus, identifying an
efcient way to achieve maximum distal en-masse
movement of the mandibular arch should be a primary
goal in Class III camouage treatment for adults.
We used the multiloop edgewise archwire technique
at the beginning of this treatment. However, the occlusal
enhancement in response to this technique depends on
the patient's cooperation and can vary with each patient.
Also, labial tipping of the maxillary incisors generally
occurs as a negative effect of anterior anchorage loss
during molar distalization. As a result, the U1-SN was
64.7 , which was 14.9 less than the initial status after
4 months of multiloop edgewise archwire treatment. Ap-
parently, the overproclined maxillary incisors compro-
mised the pleasing smile. To minimize this side effect,
we used miniscrews instead of the multiloop edgewise
archwire to reinforce the distal retraction of the
Jing et al 885

Fig 9. A, Posttreatment cephalogram; B, panoramic radiograph; C, superimposition.

mandibular arch and create enough overjet to upright
the labially inclined maxillary incisors. The miniscrews
were implanted vertically so that they would not block
the way for the distal movement of the mandibular
dentition. The mandibular incisors were successfully
retracted about 4.0 mm without undesirable tipping,
and the movement type of the mandibular molars was
almost bodily translation.
Enlow et al22 stated that it is critical to move the
occlusal plane counterclockwise during skeletal Class
III therapy. In this patient, the Frankfort horizontal to
occlusal plane angle decreased gradually, along with
an increase of the SN-GoGn angle (Table). These
changes demonstrated that the combination of
counterclockwise rotation of the occlusal plane with
clockwise rotation of mandible can be obtained not
only by the multiloop edgewise archwire technique,
but also with miniscrew-assisted mandibular arch
distalization. Multiloop edgewise archwires can recon-
struct the occlusal plane by uprighting and intruding
the posterior teeth, and extruding the mandibular
incisors with short elastics.23 However, the same effects
can be obtained by miniscrews. The mandibular arch can
be rotated counterclockwise during the distal en-masse
movement because the direction of the retraction force
applied on the miniscrews is above the center of
mandibular arch resistance, leading to a attened
occlusal plane (Fig 10). On the other hand, molar
distalization, which contributed mostly to the clockwise
rotation of mandible, was benecial for alleviating the
negative overbite. With the combination of retracted
mandibular incisors, the anterior crossbite could be

American Journal of Orthodontics and Dentofacial Orthopedics June 2013  Vol 143  Issue 6
886
Fig 10. Because the direction of the retraction force
applied to the miniscrews is above the center of mandib-
ular arch resistance, the mandibular arch can be rotated
counterclockwise when distalized, leading to a attened
occlual plane. On the other hand, molar distalization is
benecial for decreasing a negative overbite. With the
combination of these 2 factors, the anterior crossbite
can be corrected, and ideal overbite and overjet can be
established. The dotted line represents the retraction
force; the red point represents the center of mandibular
arch resistance.
easily corrected, and ideal overbite and overjet were well
established. Compared with the multiloop edgewise
archwire technique, the application of miniscrews
signicantly simplies the force system and reduces
the difculty in bending wires and maintaining
appropriate labial inclinations of the maxillary incisors,
since the force does not directly impose on those teeth.
In addition, it depends much less on the patient's
compliance. Thus, we suppose that implanting
miniscrews in the posterior area of the mandible provides
advantages for the correction of an anterior crossbite by
a similar mechanism as the multiloop edgewise archwire
technique. Moreover, in conjunction with the self-
ligation system, the lower frictional resistance might
greatly contribute to the effective distal en-masse
movement of the mandibular dentition.24-26
Another critical factor for the successful recovery of
maxillary incisor inclination was that the brackets of
these teeth were rotated 180 when we replaced all
brackets with Damon III brackets. This correction
changed the preadjusted torque of the maxillary central
incisor from 112 to 12 , and the torque of the
maxillary lateral incisors from 18 to 8 . In this way,
the labial root torque could be expressed accurately,
efciently, and gently with the outstanding performance
of the 0.019 3 0.025 beta-titanium alloy wire.
CONCLUSIONS
The use of miniscrews in the posterior area of the
mandible is an effective approach for Class III camou-
age treatment. Not only can the occlusal plane be
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Jing et al
attened in conjunction with clockwise rotation of the
mandible, but also it is benecial to control the labial
inclination of the maxillary incisors for the en-masse
mandibular arch distalization. Therefore, this technique
requires less compliance and is particularly useful for
correcting Class III patients with mild mandibular
protrusion and minor crowding. Identically, Class II
patients with a mildly protrusive maxilla are also
candidates for en-masse maxillary arch distalization
with miniscrews implanted in the posterior area of the
maxilla. The outcome of this case was stable after
1 year, although more follow-up is necessary to
determine the long-term stability.
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