CASE REPORT

Miniscrew mechanics for molar

distalization and incisor intrusion in a
patient with a Class II brachyfacial
pattern and gummy smile
 nica Garcıa-Sanz
Vanessa Paredes-Gallardo, Carlos Bellot-Arcıs, and Vero
Valencia, Spain

A gummy smile is one of the most problematic characteristics in patients with a Class II Division 2 malocclusion,
and the correction of vertical position and incisor torque is often challenging for the orthodontist. This case report
describes the orthodontic treatment of a 31-year-old woman, assisted by miniscrew mechanics for maxillary arch
distalization and correction of a gummy smile with a brachyfacial pattern. Two different mechanics were used.
Miniscrews were placed in both maxillary tuberosities, and the maxillary arch was successfully distalized, cor-
recting the Class II relationship. Interradicular miniscrews were placed for maxillary and mandibular incisor intru-
sion to correct the gummy smile, overbite, and torque. Finally, periodontal surgery was performed to lengthen the
maxillary incisor crowns. Satisfactory smile esthetics and good occlusion were achieved. Follow-up after
24 months confirmed that the outcome was stable. (Am J Orthod Dentofacial Orthop 2020;-:---)

O
ne of the most challenging objectives in the
treatment of patients with Class II Division 2
malocclusion is to correct the vertical position
and maxillary incisor torque.1 In these patients, the ret-
roclination of the maxillary incisors is a consequence of
the high pressure exerted by the lower lip, making intru-
sion and torque important treatment goals, together
with their long-term stability.2
In addition, some of these patients present excessive
gingival display, resulting in a gummy smile and the
consequent poor esthetics. For these patients, diagnosis
and treatment planning must fulfill both orthodontic
objectives and the patient's expectations.
The decision to treat this vertical malocclusion with
either orthodontics alone or in combination with or-
thognathic surgery will depend on the etiology and
severity of the problem along with other individual fac-
tors.3 Orthognathic surgery is a common approach when
From the Orthodontics Teaching Unit, Department of Stomatology, Faculty of
Medicine and Dentistry, University of Valencia, Valencia, Spain.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Ver onica Garcıa-Sanz, Orthodontics Teaching Unit,
Department of Stomatology, Clınica Odontol ogica, Universitat de Valencia, C/
Gasco Oliag 1, Valencia 46010, Spain; e-mail, veronica.garcia-sanz@uv.es.
Submitted, March 2019; revised and accepted, April 2019.
0889-5406/$36.00
Ó 2020 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.04.038
the cause is anterior maxillary excess, with LeFort I os-
teotomy being the most common procedure.4 When sur-
gical treatment is not an option because of the patient's
unwillingness to undergo the procedure, or when there
is no skeletal maxillary vertical excess, the use of
miniscrews should be considered as this offers an
effective method for attaining maxillary incisor intrusion
and so correction of the gummy smile.5
Miniscrews offer the advantages of immediate loading,
multiple placement sites, relatively simple placement
and removal, and minimal expense.6,7 When placing
miniscrews in the anterior interradicular areas, in
combination with appropriate orthodontic mechanics,
the intrusion of maxillary and mandibular incisors can
be achieved, improving overbite.8,9
In addition, mechanics for maxillary molar distaliza-
tion to correct a Class II malocclusion can be simplified
by placing miniscrews in the maxillary tuberosity.
Although this area is not ideal because of poor bone
quality, the implementation of proper placement proto-
cols and biomechanical design can lead to outstanding
results.10
If there is a deficiency in the upper lip length,
cosmetic techniques such as lip repositioning can obtain
good results in terms of gingival display,11 although this
treatment might show some relapse.12
When the patient presents reduced maxillary central
incisor crown height because of altered passive eruption,

1
2 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz

periodontal surgery can be performed to lengthen the
incisors' clinical crowns, which will improve the gum-
teeth relationship.13
This case report describes the nonsurgical orthodontic
correction of a brachyfacial pattern with Class II Division
2 malocclusion and excessive gingival display treated
with miniscrews for maxillary and mandibular incisor
intrusion, and molar distalization to provide adequate
vertical position and incisor torque. Treatment enhanced
smile esthetics and provided good long-term stability.
DIAGNOSIS AND ETIOLOGY
A 31-year-old woman complaining of a gummy smile
and maxillary incisor crowding visited the clinic seeking
orthodontic treatment.
The frontal facial photograph shows a gingival
display of 4-5 mm. The maxillary incisal exposure at
rest was slightly excessive. The patient's facial profile
was convex, and the upper lip appeared protruded. There
was scarce chin projection, and her mentolabial angle
was obtuse (Fig 1). The upper lip length was within the
normal range, measuring 22 mm from subnasale
to stomion, although there was an alteration in lip
mobility; the excessive difference between the position
of the patient's upper lip at rest and full smile indicated
upper lip hypermobility.
Intraoral photographs and study models show an
incomplete molar and canine Angle Class II relationship.
The overjet and overbite were 3.6 mm and 7.3 mm,
respectively. Mandibular dentition showed an excessive
curve of Spee because of the overeruption of the
mandibular incisors. The maxillary dental midline was
deviated to the right concerning the facial midline,
whereas the mandibular dental midline was centered
concerning the mandible, so maxillary and mandibular
dental midlines did not match. The arch discrepancy in-
dex was 7.1 mm and 3.5 mm for the maxillary and
mandibular arches, respectively. The maxillary central
incisor crown height was short (7.9 mm), and the 4
maxillary incisors presented altered passive eruption
(Figs 1 and 2). The patient's periodontal examination
indicated good periodontal conditions.
Cephalometric analysis (Fig 3, A and B; Table)
showed a skeletal Class II (ANB, 5.6 ) with a severe bra-
chyfacial pattern (facial axis, 94.3 ; FMA, 25.1 ; lower

Fig 1. Pretreatment facial and intraoral photographs.

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Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
Fig 2. Pretreatment study models.
lower facial height, 71.6 mm). The maxillary and
mandibular incisors were lingually inclined (PP-U1,
91 ; IMPA, 76.1 ), and as a result, the interincisal angle
was increased (164.1 ).
The third molars had already been extracted by the
oral surgeon at an earlier date (Fig 3, C).
Based on these findings, the patient was diagnosed
as presenting a brachyfacial pattern with skeletal and
dental Class II Division 2, excessive overbite and overjet,
increased curve of Spee, and excessive gingival display
with an altered passive eruption of the maxillary incisors.
Periodontal health was good.
TREATMENT OBJECTIVES
The treatment plan focused on achieving optimal
overjet and overbite, incisor torque, and on improving
the gummy smile to provide adequate esthetics, func-
tion, and long-term stability, in the shortest possible
treatment duration, without any need for patient
compliance.
Treatment objectives were (1) to establish a skeletal
and dental Angle Class I relationship, (2) to flatten the
curve of Spee to achieve a harmonious smile, (3) to
reduce the gummy smile aiming at a more attractive
smile, (4) to obtain adequate incisor torque, and (5) to
attain a balanced facial profile.
American Journal of Orthodontics and Dentofacial Orthopedics
3
TREATMENT ALTERNATIVES
The orthognathic surgical approach, such as LeFort
impaction, was not considered in this patient, because
the gummy smile was not due to anterior vertical maxil-
lary excess.
Orthodontic treatment options involving extraction
and nonextraction can be contemplated for Class II Divi-
sion 2 malocclusion in an adult presenting negative arch
discrepancy. To avoid extractions, effective molar distal-
ization may be performed. However, when no distaliza-
tion is desired or cannot be performed because of the
presence of third molars, maxillary premolar extractions
must be carried out to avoid excessive proinclination of
the maxillary incisors, leaving a molar Class II and canine
Class I malocclusion. The patient did not want any
premolar extraction, and because third molars were
not present, a non-extraction treatment was chosen.
Miniscrews may be used to correct a gummy smile
successfully, and to flatten the curve of Spee. Conven-
tional orthodontic methods, such as intrusion arches,
utility arches, extraoral appliances, or rubber bands,
can lead to undesirable side effects and also depend
on patient cooperation. These unwanted side effects
are extrusion and flaring of the posterior teeth, and
the clockwise rotation of the mandible caused by the
extrusion of the posterior teeth, which will worsen the
Class II convex profile in many patients and also lead
to an increase in the incidence of relapse in adults.14,15
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4 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz

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

Maxillary central incisor crown height was short due
to maxillary incisor altered passive eruption, so maxillary
incisor periodontal surgery was planned. Because maxil-
lary central incisor anatomy was appropriate, composite
restorations were not a good option.
Finally, because of the hypermobility of the upper lip,
the possibility of Botox or lip repositioning procedures
were considered and proposed to the patient. Neverthe-
less, these treatments are not always stable.12 In the end,
these procedures were not necessary because, after or-
thodontic treatment, the correction of the gingival smile
was satisfactory.
TREATMENT PROGRESS
A 0.022 3 0.028-in slot preadjusted edgewise-ceramic
appliance was placed on the maxillary arch (Clarity
Advanced; 3M Unitek, Monrovia, Calif) because of patient
preferences, whereas 0.022 3 0.028-in slot metal appliance
system (Victory Series; 3M Unitek) was used on the mandib-
ular arch. MBT prescription was chosen for both maxillary
and mandibular bracket appliances.
The treatment plan was developed in 2 stages. The
initial phase involved the insertion of a miniscrew into
each maxillary tuberosity to correct the Class II malocclu-
sion (length, 12 mm; diameter, 2 mm; Jeil Medical Corpo-
ration, Seoul, Korea) (Fig 4, A and B). These screws were
inserted under local anesthesia at the start of treatment.
Figure 4, C shows the diastema produced by the distaliza-
tion effect of the miniscrews. After 6 months, a Class I rela-
tionship was achieved, so the miniscrews were removed.
In the second phase, 2 more miniscrews were placed
in the maxillary incisor area to obtain intrusion of the
maxillary incisors and to correct the gummy smile
(length, 10 mm; diameter, 1.8 mm; Jeil Medical

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Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz 5

inserted in the interradicular areas under local anesthesia

Table. Pretreatment, posttreatment, and postreten-
perpendicular to the teeth to endure the intrusion forces.
tion cephalometric summary
After 4 months, the intrusion of the anterior teeth was
Cephalometric attained, so the miniscrews were removed.
analysis Pretreatment Posttreatment Postretention
SNA angle ( ) 83.1 82.9 83.0 Miniscrew mechanics
SNB angle ( ) 77.5 78.3 78.1
ANB angle ( ) 5.6 4.6 4.5 Maxillary arch distalization is shown in Figure 6, A.
Wits appraisal (mm) 4.7 0.2 0.0 Miniscrews were used as direct anchorage units, and
U1-palatal plane ( ) 91.0 109.7 110.0 force was applied to the teeth with a power chain. The
IMPA (L1-Mp) ( ) 76.1 96.5 96.5
Interincisal angle ( ) 164.1 128.3 128.0
miniscrew heads should all be the same level as the molar
Overjet (mm) 3.6 2.2 2.2 bracket to avoid producing molar intrusion (Fig 4, A).
Overbite (mm) 7.3 1.0 1.1 The same power chain with 5 links was used to pull
Facial axis 94.3 96.3 96.0 the first and second molars simultaneously. An initial
(NaBa-PtGn) ( ) 50 g of force was applied to the molars during the first
FMA (Mp-FH) ( ) 25.1 23.0 23.0
Upper facial height 48.0 48.0 48.0
month, later increased to 100 g of force. To avoid the
(N-ANS) (mm) side effects of 1-side traction, we added lingual attach-
Lower facial height 71.6 70.0 70.2 ments to the posterior teeth, so traction could be per-
(ANS-Me) (mm) formed from both buccal and lingual sides as needed.
Mandibular length 76.0 76.0 76.0 The arch expansion was attained by applying higher
(Go-Gn) (mm)
Upper lip length 22.3 22.0 22.1
forces to the lingual chain. The archwire should be
(Sn-StSup) (mm) long enough to allow molar distalization, bent at a dis-
tance, so that it does not cause discomfort to the patient.
Mandibular incisor intrusion is shown in Figure 6, B.
Corporation), whereas 1 single miniscrew (length, Miniscrews were also used as direct anchorage units,
10 mm; diameter, 1.8 mm; Jeil Medical Corporation) applying a light force to the archwire (5-15 g of force),
was placed in the mandibular incisor area to flatten in this case with an elastic thread. One single miniscrew
the curve of Spee (Fig 5, A and B). The screws were was placed between mandibular central incisors, located

Fig 4. Mechanics for maxillary arch distalization using min-

iscrews placed in the maxillary tuberosity: A, illustration of
miniscrew inserted in the tuberosity; B, miniscrews placed Fig 5. Mechanics for maxillary and mandibular incisor
distal to maxillary molars and elastic chains for distalization; intrusion using miniscrews: A, intraoral photograph; B,
C, diastemas produced by distalizing mechanics. periapical radiographs.

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6 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
anterior to the center of resistance, aiming to achieve
intrusion as well as labial tipping of the incisors.
Maxillary incisor intrusion is shown in Figure 6, C.
Light forces were also applied (5-15 g of force) with an
elastic chain. Because both miniscrews were placed pos-
terior to the center of resistance, intrusion with less
labial tipping was expected.
Orthodontic alignment and leveling were achieved us-
ing nickel-titanium 0.014-in, 0.016-in, 0.019 3 0.025-in
and 0.021 3 0.025-in archwires, whereas stainless steel
0.016-in, 0.019 3 0.025-in and 0.021 3 0.025-in arch-
wires were employed to correct the dental arches. Addi-
tional torque to the maxillary incisors was necessary
during treatment, so Warren torquing springs (Rocky
Mountain Orthodontics, Denver, Colo) were used in combi-
nation with the stainless steel 0.021 3 0.025-in archwires.
Intermaxillary 0.25-in elastics were used for Class II
and midline correction. Short triangular intermaxillary
0.125-in elastics (super thread; Rocky Mountain
Orthodontics) were used to obtain premolar and canine
interdigitation.
Just before removing the fixed appliances, peri-
odontal surgery of the central and lateral maxillary
incisors was performed to lengthen the clinical crowns
because they presented altered passive eruption, and
the crowns were short. Accurate evaluation of the excess
of the keratinized tissue was conducted to determine the
amount to be removed, in consideration of the crown
proportions (Fig 7).
The total duration of the orthodontic treatment was
approximately 20 months. After removing the orthodon-
tic appliances, canine-to-canine fixed lingual retainers
Fig 6. Illustrations of the mechanics used: A, maxillary arch distalization; B, mandibular incisor intru-
sion; C, maxillary incisor intrusion.
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were bonded on both arches, and thermoplastic retainers
were provided to be worn at night.
TREATMENT RESULTS
Because of the implementation of 2 types of
miniscrew mechanics (2 miniscrews for Class II correc-
tion by molar distalization, and 3 for incisor intrusion,
gummy smile reduction, and flattening the curve of
Spee), the patient's malocclusion greatly improved,
and the orthodontic treatment time was significantly
shortened with no need for patient compliance.
An acceptable occlusion and a satisfactory facial pro-
file were also obtained. Posttreatment facial photo-
graphs showed that a balanced and harmonious face
was achieved (Fig 8). The patient was very satisfied
with the treatment results, which completely fulfilled
her expectations. The mentolabial angle improved
significantly, providing better esthetics to the facial
profile by increasing chin projection.
Posttreatment intraoral pictures and dental cast
models illustrate good dental interdigitation. In addi-
tion, an Angle Class I molar relationship and an accept-
able interincisal relationship were established. The
gummy smile was substantially reduced (Figs 8 and 9).
The cephalometric analysis also showed significant
changes to the patient's measurements (Figs 10, A and
B; Table). The ANB angle decreased from 5.6 to 4.6 ,
and the Wits appraisal from 4.7 mm to 0.2 mm. This
discrepancy between the ANB angle and the Wits
appraisal was due to the counter-clockwise rotation of
the occlusal plane because the mandibular plane
Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
Fig 7. Clinical crown lengthening of maxillary incisors.
confirmed. Maxillary and mandibular incisors were
buccally inclined (PP-U1, 109.7 ; IMPA, 96.5 ). Facial
pattern measurements changed significantly (facial
axis from 94.3 to 96.3 ; FMA from 25.1 to 23 ).
Acceptable root parallelism was achieved, and neither
root resorption nor marginal bone loss in the periodontal
tissues were observed (Fig 10, C). Periodontal health
remained sound throughout the treatment period.
Fig 8. Posttreatment facial and intraoral photographs.
American Journal of Orthodontics and Dentofacial Orthopedics
7
Figure 11 shows superimpositions of pretreatment and
posttreatment digital dental models, which demonstrate
that at the end of treatment, the overerupted mandibular
incisors were significantly corrected and intruded, and the
excessive curve of Spee was also flattened. The difference
in torque and vertical position of maxillary incisors before
and after treatment was also remarkable. Intrusions of
1.8 mm and 2.1 mm were achieved for maxillary and
mandibular incisors, respectively.
After a 24-month retention period, the facial es-
thetics and occlusion achieved at the end of treatment
were perfectly maintained (Fig 12).
Postretention cephalometric analysis (Fig 13, A and B;
Table) showed no changes compared to posttreatment
analysis (Fig 10, A and B; Table). In addition, the postreten-
tion panoramic radiograph showed no changes (Fig 13, C)
compared to posttreatment analysis (Fig 10, C).
Figure 14, A, B, and C show superimpositions of pre-
treatment, posttreatment, and postretention cephalo-
metric tracings. These findings show the dental,
skeletal, and soft tissue changes achieved as the result
of treatment and stability in the postretention period.
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8 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
Fig 9. Posttreatment study models.
The intrusion and proclination of maxillary and mandib-
ular incisors achieved at the end of treatment remained
stable after the 24-month retention period.
DISCUSSION
Chin projection and the mentolabial angle improved
after treatment because of the counter-clockwise rota-
tion of the mandible, so the patient's convex facial pro-
file and protruded upper lip became straighter and more
balanced. A gummy smile can be the result of a combi-
nation of factors including vertical maxillary excess,
small maxillary central incisor crown height, altered pas-
sive eruption, a short upper lip, and a hyperactive upper
lip.16 The main etiologic factors in the present case were
excessive incisor extrusion, altered passive eruption, and
hyperactivity of the upper lip. The maxillary central
incisor crown height was shorter than normal (7.9 mm)
because of altered passive eruption; the correct value
in an adult female was 9.6 mm.17 Although the upper
lip appeared to be clinically short at the start of treat-
ment, the distance from the subnasale landmark to the
stomion was 22 mm, which is within the normal range.
Interestingly, several studies have shown that in most
cases of excessive gingival display, the upper lip length
is normal, although, the lip appears clinically short.18
Maxillary and mandibular incisor intrusion was 1 of
the main treatment objectives because the severe
- 2020  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
overbite was caused by the overeruption of the incisors
with the consequently increased curve of Spee. The
intrusion of the maxillary and mandibular incisors was
successfully performed using miniscrews without any
side effects as reported by other authors,19,20 which
shortened treatment time and did not require patient
compliance. By applying orthodontic mechanics with
miniscrews, 1.8 mm and 2.1 mm intrusions of the maxil-
lary and mandibular incisors were achieved, respectively.
These intrusion values are greater than those that can be
obtained using conventional techniques, as stated in a
meta-analysis conducted by Ng et al21 which concluded
that segmented arch techniques could produce 1.5 mm
and 1.9 mm of maxillary and mandibular incisor intru-
sion, respectively. One of the possible undesirable effects
of intrusion mechanics is root resorption, which did not
occur in the present case, as shown by the final pano-
ramic radiograph (Fig 10, A).
Different mechanics can be applied for incisor intru-
sion, according to the orthodontic movement sought. A
study by Lindauer and Isaacson22 shows the different ef-
fects that can be obtained from the point where force is
applied concerning the center of resistance of the ante-
rior teeth during intrusion and extrusion movements. In
the present case, for mandibular incisors, 1 miniscrew
was placed in the interradicular space between the 2
central incisors, this location being anterior to the center
Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
Fig 10. Posttreatment records: A, lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.
of resistance. In this way, the force applied produced less
intrusion but more buccal tipping, the desired move-
ments for the lingually inclined mandibular incisors
(Fig 6, B). However, for maxillary incisor intrusion, 2
miniscrews were inserted. These were placed between
the roots of canines and lateral incisors, so the force
was applied posterior to the center of resistance, produc-
ing less labial tipping but more intrusion to correct the
gummy smile (Fig 6, C). When placing the miniscrews,
maxillary and mandibular convexity should be taken
into consideration to avoid impingement of the elastic
thread.
Because 1 of the main goals of the treatment was the
correction of the gummy smile, the stability of the treat-
ment largely depended on the prevention of extrusion of
the incisors. After the 24-month retention period, both
maxillary and mandibular incisor intrusion with
American Journal of Orthodontics and Dentofacial Orthopedics
9
miniscrews was very stable, as a previous case report
has shown.23
Warren torquing spring devices (Rocky Mountain Or-
thodontics) were used to provide the additional maxil-
lary incisor torque needed.24 Excessive linguoversion is
usually caused by the pressure of the lower lip on the
overerupted maxillary incisors. For this reason, achieving
the ideal maxillary incisor position and torque was 1 of
the main treatment goals in the present case, because
a good result in this area would provide long-term sta-
bility.2 As explained by Sarver and Ackerman,25 incisor
proclination can have a dramatic effect on incisor
display, which appears reduced if these teeth are exces-
sively flared. In the present case, incisor inclination
provided good and harmonious smile esthetics.
Aiming to control maxillary incisor inclination, avoid
excessive buccal tipping during alignment, and correct
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10 Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz

Fig 11. Superimposition of pretreatment and posttreatment digital dental models.

Fig 12. Postretention facial and intraoral photographs.

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Paredes-Gallardo, Bellot-Arcıs, and Garcıa-Sanz
Fig 13. Postretention records: A, lateral cephalogram; B, cephalometric tracing; C, panoramic radiograph.
the dental Class II malocclusion with minimum side ef-
fects, miniscrews were placed in both maxillary tuberos-
ities to distalize the maxillary arch (Figs 4 and 6, A)
taking advantage of the fact that the third molars had
been extracted at a much earlier date. Good results
were obtained in this regard with none of the side effects
reported by other authors,10 even though microscrew
placement in this area may lead to complications
because of the poor quality of the bone, high morpho-
logic variation between patients,26 and the risk of maxil-
lary sinus perforation. Although complications of this
type are rarely reported, a minimum sinus floor thickness
of 6.0 mm or more is recommended to avoid miniscrew
perforation of the maxillary sinus.27
In the present treatment, only a small number of
miniscrews were needed. These devices offered many ad-
vantages such as no need for laboratory work, ease of
placement and removal, immediate load application,
minimal anatomic limitation, simple treatment
American Journal of Orthodontics and Dentofacial Orthopedics
11
mechanics, a low rate of complications, minimal eco-
nomic cost to the patient, reduced treatment time,
versatility, and no need for patient compliance.
As diagnosed before treatment, the passive eruption
was altered. After careful evaluation of the keratinized
soft tissue and alveolar bone level, periodontal surgery
was conducted in the maxillary incisors to improve smile
esthetics and provide ideal crown proportions. The
integrity of the dentogingival junction must be re-
spected to ensure good and stable outcomes; this will
depend on detailed and accurate diagnosis.28 Satisfac-
tory results were obtained in this case, which remained
stable throughout the retention period.
CONCLUSIONS
The use of 2 different types of miniscrew mechanics
made it possible to correct the brachyfacial pattern with
Class II Division 2 malocclusion and a gummy smile. This
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12
Fig 14. 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 menton.
outcome was achieved successfully without premolar ex-
tractions. Orthodontic treatment time was significantly
shortened without any need for patient compliance. In
this case, the key to a successful outcome in terms of smile
esthetics and long-term stability was the adequate posi-
tioning and torque of the maxillary incisors.
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