Journal of the World Federation of Orthodontists 6 (2017) 28e34

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Journal of the World Federation of Orthodontists

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Research

Orthodontic treatment of Class III malocclusion with lower

extraction and anchorage with mini implants: Case report
Eduardo de Lima a, Fernanda Brum a, Maurício Mezomo a, Carlos Eduardo Pasquali a,
Marcel Farret b, *
a
Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
b
Private practice, Santa Maria, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: This article reports the case of an adult patient with Class III malocclusion with mandibular deviation to
Received 16 May 2016 right side and right anterior and posterior crossbite treated by retraction of the lower teeth with the aid
Received in revised form of mini implants in the retromolar region on both sides. The patient opted to not perform surgery for
7 January 2017
correction of facial asymmetry, thus the treatment consisted of asymmetric extraction (34 and 38) and
Accepted 13 February 2017
placement of absolute anchorage devices distal to the lower second molars in the retromolar area, which
assisted in the distal movement of the lower molars and retraction of the lower anterior teeth through
springs and elastic. At the end of treatment, the patient has achieved Class I, except only the right side,
Keywords:
Class III malocclusion
which achieved molar ratio Class II. After a follow-up period of 2 years, the results remain stable. In this
Mini implants case in a patient with moderate facial asymmetry, it was possible to restore the smile esthetics only with
Nonsurgical treatment tooth movement through the use of absolute anchorage of mini implants for distalization of molars and
anterior teeth.
Ó 2017 World Federation of Orthodontists.

1. Introduction the results of the orthodontic treatment. The insertion of mini

implants is a less invasive procedure and it is well accepted by
In adult patients, the treatment options for Class III malocclusion patients, representing a good option for mild discrepancies. On the
depend on the skeletal discrepancy, facial profile, and patient’s other hand, the insertion of mini plates is more invasive, but is
chief complaint. Cases with slight discrepancies may be treated required in cases of moderate discrepancies [4,9,12].
through orthodontic camouflage, whereas severe cases require In this article, we report a case of a 36-year-old woman with a
treatment in combination with orthognathic surgery [1e3]. Class III malocclusion associated with an anterior and unilateral
In borderline cases, in which the facial profile is esthetically posterior crossbite and deviation of the mandible and lower
acceptable, good results may be obtained with orthodontic midline to the right side. The orthodontic treatment was based on
camouflage [1e4]. The commonly used biomechanics strategies for the distal movement of the lower dentition and was achieved with
Class III camouflage are the use of facemask therapy for mesial skeletal anchorage provided by mini implants inserted into the
movement of the upper teeth and Class III elastics, often associated retromolar area on both sides of the mandible. The final and 2-year
with lip bumpers, sliding jigs, and multiloop archwires [5e9]. follow-up records showed an attractive smile and normal, func-
However, all of these mechanics rely on patient cooperation or have tional occlusion.
potential side effects [10,11]. In this context, skeletal anchorage
through mini implants or mini plates increases the foreseeability of
2. Diagnosis and etiology

A 36-year-old woman sought orthodontic treatment at the

All authors have completed and submitted the ICMJE Form for Disclosure of Department of Orthodontics of the Pontifical Catholic University of
Potential Conflicts of Interest, and none were reported. Rio Grande do Sul, Brazil, with the chief complaint of “wrong bite.”
Author have obtained and submitted the patient signed consent for images The frontal facial analysis revealed a mandibular deviation to the
publication.
* Corresponding author. Private practice, 1000/113 Floriano Peixoto St., Santa
right side and an increased lower third of the face. In the smile
Maria 97015e370, Brazil. analysis, there was a greater display of the lower incisors instead
E-mail address: marcelfarret@yahoo.com.br (M. Farret). of the upper incisors. A lower midline deviation to the right side

2212-4438/$ e see front matter Ó 2017 World Federation of Orthodontists.

http://dx.doi.org/10.1016/j.ejwf.2017.02.003
 E. de Lima et al. / Journal of the World Federation of Orthodontists 6 (2017) 28e34 29

Fig. 1. Pretreatment facial photographs.

(4 mm), associated with an anterior crossbite, worsened the Obtain a molar Class I relationship on the left side and Class II on
unesthetic condition of the smile (Fig. 1). In the intraoral photo- the right side.
graphs and dental casts, we observed that second premolars and Correct the lower midline.
the left first premolar were absent in the upper arch, whereas in Eliminate the crowding on the lower arch.
the lower arch, the right second and third molars were absent. In Improve the esthetics of the smile.
occlusion, the first molars showed a Class I relationship, but ca-
nines showed a Class III relationship. A posterior crossbite in the 2.2. Treatment alternatives
right side extended to the anterior region, including the central
incisors. The lower arch had a negative discrepancy of 3 mm Two alternatives were suggested for this patient. The first option
(Figs. 2 and 3). In the panoramic radiograph, the tooth absences was orthodontic decompensation followed by orthognathic
were confirmed and all of the present roots were found to be in surgery, with mandibular setback and correction of the deviation.
good condition. A lateral cephalogram and cephalometric mea- This treatment plan would fulfill all the necessities of the case;
surements showed a skeletal Class I pattern with proclined upper however, facial esthetics was not the main complaint of the patient
and lower incisors (Fig. 4). and the mandibular deviation was considered acceptable to her.
Furthermore, we believed that the dental asymmetry caused by the
2.1. Treatment objectives skeletal deviation could be corrected through orthodontic move-
ment without orthognathic surgery. Based on that, the orthog-
The main treatment objectives were as follows: nathic surgery was discarded. The second option was orthodontic
camouflage, with extraction of the lower left first premolar with
Eliminate the anterior and posterior crossbite. skeletal anchorage. Mini plates were first considered because the
Obtain a Class I canine relationship on both sides. total time of treatment could be reduced, moving all teeth at once;

Fig. 2. Pretreatment intraoral photographs.

30 E. de Lima et al. / Journal of the World Federation of Orthodontists 6 (2017) 28e34

Fig. 3. Pretreatment dental casts.

however, the patient refused this option because of the complexity slightly contracted to correct the posterior crossbite. Mini implants
of the surgical procedures to insert and to remove mini plates. measuring 1.3  7.0 mm (Neodent, Curitiba, PR, Brazil) were
Therefore, mini implants were chosen as a good option, associated inserted into the mandible, distal to the right first molar, and into
with lower extraction, to correct the asymmetry and anterior the left retromolar area (Fig. 5). At the right side, elastomeric chains
crossbite and reach an ideal overjet and overbite. were attached from the mini implant to the buccal and lingual
surfaces of the first molar, which was moved distally, as was the
2.3. Treatment progress second premolar. Then, with enough space, the first premolar was
bonded and aligned. On the left side, the second and first molars
To start the treatment, fixed 0.022  0.028-inch edgewise and the second premolar were tied together to the mini implant,
standard brackets were bonded on the upper and lower teeth, with forming the anchorage unit for retraction of the canine with
the exception of the lower right first premolar. The extraction of the elastomeric chains (Fig. 5). After canine retraction on the left side,
lower left first premolar and lower left third molar was requested. there was enough space for retraction of the lower incisors and
The initial alignment and leveling was performed with a stainless correction of the deviated midline. The incisors were retracted with
steel (SS) coaxial 0.0175-inch archwire, followed by round 0.016- SS 0.018  0.025-inch archwire with bull loops to eliminate the
inch, 0.018-inch, and 0.020-inch archwires. From the beginning, anterior crossbite. In the maxilla, open coil springs were inserted
the upper archwires were expanded and the lower archwires were between the left canine and left first molar, creating space for

Fig. 4. Pretreatment radiographies.

 E. de Lima et al. / Journal of the World Federation of Orthodontists 6 (2017) 28e34 31

Fig. 5. Intraoral photographs of the mechanics. Mechanics on the lower arch after the distalization of the right teeth with elastomeric chains connected to the mini implant and
buccal and lingual surface of each tooth and during the distalization of the left teeth with molars and premolars connected to the mini implant increasing the anchorage.

prosthetic implants in the first premolar area. During finishing, SS during the retention period (Figs. 7 and 8). The panoramic
rectangular 0.019  0.025-inch ideal upper and lower archwires radiograph showed parallelism of the roots without resorption.
and one-eighth-inch elastics were used at the canine region to There was adequate space for implant-prosthetic rehabilitation
improve the intercuspation. in the region of the upper left first premolar. Final cephalometric
measurements showed that the upper and lower incisors were
3. Results uprighted and cephalometric superimposition highlighted the
changes in the position of the incisors, in addition to the lower
At the end of treatment, the facial analysis revealed that the molar distalization and lower lip retraction in response to the
asymmetry of the mandible persisted, as expected; however, retraction of the lower incisors (Fig. 9; Table 1). The 2-year
there was great improvement in the esthetics of the smile. The follow-up control demonstrated excellent stability of the
dentition now appears attractive, exhibiting a wider upper arch obtained results, with implant-prosthetic rehabilitation of the
and a greater display of the upper incisors instead of the lower upper left first premolar (Fig. 10).
incisors (Fig. 6). Intraoral photographs and dental casts revealed
that the treatment objectives were reached: the molars had a 4. Discussion
Class II relationship on the right side, a Class I relationship on
the left side, and the canines were in a Class I relationship. When adult patients have an accentuated facial asymmetry or
Similarly, ideal overjet and overbite were obtained, anterior and severe anteroposterior skeletal discrepancies, orthodontic treat-
posterior crossbites were corrected, and the upper and lower ment associated with orthognathic surgery is the primary choice
midlines matched. The upper right first and second molars were [13]. However, when the facial asymmetry is considered slight to
kept overexpanded at the end of treatment, preventing relapse moderate, does not compromise the facial esthetics, or is not part of

Fig. 6. Posttreatment facial photographs.

32 E. de Lima et al. / Journal of the World Federation of Orthodontists 6 (2017) 28e34

Fig. 7. Posttreatment intraoral photographs.

the chief complaint of the patient, orthodontic compensation may Moreover, distal movement of the lower molars is reputed more
be indicated to obtain a harmonic smile and correct masticatory difficult to perform than that of the upper molars [10,17]. In this
function [4,12,14,15]. context, skeletal anchorage arose as an excellent option, which
Several treatment modalities have been proposed over the years brought a new paradigm to orthodontics. Recently, some authors
with the intent of achieving distal movement of the upper molars; described cases in which orthognathic surgery was avoided because
however, only a few descriptions have been found for the lower the skeletal anchorage with mini implants or mini plates made
arch [10]. Among the alternatives for distal movement of the molars camouflage possible with satisfactory results in esthetics or
in the lower arch are lip bumpers, Class III elastics associated or not function [4,12,14,15]. In particular, the skeletal anchorage
to sliding jigs, and the Nance lingual arch to improve the anchorage overwhelms the desirable orthodontic movements, eliminating the
[4,9,10,16]. Nevertheless, all those mechanics depend on patient side effects [17].
cooperation and provoke undesirable effects, such as anchorage In the case here described, the anteroposterior dental discrep-
loss, lower incisor proclination, and upper incisor proclination. ancy was moderate; therefore, mini implants and plates were

Fig. 8. Posttreatment dental casts.

 E. de Lima et al. / Journal of the World Federation of Orthodontists 6 (2017) 28e34 33

Fig. 9. Posttreatment radiographies, posttreatment cephalogram, and total superimposition.

considered as good anchorage units to camouflage this malocclu- gingiva, hindering both access and mechanics [12]. In the present
sion. If elected, the mini plates would be placed on the external case report, because there was no space between the lower pos-
oblique ridge of both sides of the mandible. The major advantage of terior roots, we opted for insertion in the retromolar area, where
this would be the possibility of moving all the lower teeth at once, spaces were provided by molar absence and extraction. One of the
reducing the duration of treatment and eliminating the necessity of main concerns related to the Class III treatment through distal
lower left first premolar extraction [18,19]. Nonetheless, the patient movement of the lower dentition is the stability of the results
refused the mini plates because of the complexity of the surgery obtained. The lower teeth on the right side were moved distally. The
required to insert and remove the devices and opted for mini lower left first premolar was extracted for midline correction and
implants instead [19e21]. incisor retraction, provoking a reduction on the lower arch’s length
Different mechanics based on mini implants have been and perimeter, and also a reduction on the space available for the
described for the correction of Class III malocclusions. Usually, mini tongue, which could make this case unstable. As such, certain as-
implants are inserted between the first and second premolar roots pects must be observed in these cases to improve the stability after
or between the second premolar and first molar roots [4,11,12,15]. In treatment: establishment of ideal overjet and overbite, good
cases in which there is not enough space available between the intercuspation, and use of a retainer on the lower arch indefinitely.
roots in the mandible, the mini implants can be placed on the upper Hopefully, the results obtained in this case remain stable, as shown
arch, between the second premolar and the first molar, but this in the 2-year follow-up control.
alternative relies on patient compliance regarding use of Class III
elastics from the mini implant to the lower arch [12]. Another
alternative, if there is enough space available, is vertical insertion 5. Conclusion
into the retromolar area. The great advantage here is the possibility
of larger movements without the risk of the mini implant In the case described, with moderate facial asymmetry, it was
possible to obtain good smile esthetics and functional occlusion
contacting the roots. However, the disadvantage is the higher
possibility of the mini implant becoming encapsulated by the with orthodontic movements using the aid of mini implants as
units of anchorage.

Table 1
Cephalometric measurements References
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Fig. 10. Intraoral photographs 2 years posttreatment.