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Case Report

Nonextraction Treatment with En‑Masse Distalization of Maxillary

Dentition using Miniscrews
Shailesh V Deshmukh1,2, Kinjal J Vadera3

Dr.
1,2,3
Miniscrews have been increasingly used in orthodontics for distalization of the

Abstract
1
Deshmukh’s Orthodontic maxillary molars and also the entire arch. The two case reports in this article
Center, 2Professor Bharati describe the en‑masse distalization of the maxillary arch in Class  II patients
Vidyapeeth University with different growth patterns with the help of four miniscrews in the arch. The
Dental College and Hospital, placement of two miniscrews and their relative position on either side of the
Pune, Consultant Deenanath maxillary arch were used to control the magnitude and direction of force for
Mangeshkar Hospital,
3
Deshmukh’s Orthodontic
distalization of the entire arch. At the end of the treatment, Class  I molar and
Center, Pune, Maharashtra, India canine relationships were achieved in both the cases without the need for extraction
or loss of anchorage.
Received: 13‑11‑2017
Accepted: 27‑04‑2018 Keywords: Class II malocclusion, en‑masse distalization, miniscrews

Introduction and superimpositions in both the case reports have

been carried out using Dolphin 10.2 version imaging
T he goal of any orthodontic treatment is to
achieve desired tooth movement with a minimum
number of undesirable side effects.[1] Strategies for
software.

anchorage control have been a major contributing Case Reports

factor in achieving successful orthodontic treatment.
Edward H. Angle was one of the earliest to advocate
the use of equal and opposite appliance forces to
control anchorage. Traditional methods of reinforcing
anchorage such as increasing the number of teeth
bilaterally and using the musculature or extraoral
devices have unwanted side effects or require patient
compliance.[2] Miniscrews have overcome many of
these problems regardless of whether a single molar
or the entire posterior segment is to be moved.
Sagittal movement of the dentition in nonextraction
cases is often difficult and time‑consuming.[3] Sagittal
movement carried out with the help of skeletal
anchorage minimizes the side effects, no special
compliance is required, and the incisor positions and
facial profile can be efficiently controlled.[4‑6] There
are many Class II cases where the face dictates
nonextraction treatment. Transition from extraction
to nonextraction treatment using miniscrews for
en‑masse distalization of the maxillary dentition in
select Class II cases has been discussed in this article
through two case reports. All cephalometric analyses
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Case 1
A 20‑year‑old female patient presented with a chief
complaint of crooked teeth in both arches. Intraoral
examination showed a Class II division 2 malocclusion
with an end‑on molar relationship on both the sides
and a canine relationship of Class II on the right
side and end‑on on the left side. She had a deep bite
(6‑mm overbite) and an overjet of 4 mm. Her upper
left first premolar was in scissor bite. The upper arch
exhibited a crowding of 5 mm. She had a straight
profile with a sharp nose and a prominent chin
[Figure 1a and b].
Cephalometric analysis revealed a skeletal Class I
relation with an ANB of 3.1° and a horizontal growth
pattern [Figure 2a, b and Table 1]. Figure 2c shows the
pretreatment orthopantomogram (OPG) of the patient.
Address for correspondence: Dr. Kinjal J. Vadera,
“Devikripa” Shri Dashbhuja Co‑Op Hous. Soc.,
Karve Road, Paud Phata, Pune ‑ 411 038, Maharashtra, India.
E‑mail: kinjalvadera10@gmail.com
This is an open access journal, and articles are distributed under the terms of the
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DOI: How to cite this article: Deshmukh SV, Vadera KJ. Nonextraction treatment
10.4103/jios.jios_235_17 with en-masse distalization of maxillary dentition using miniscrews. J
Indian Orthod Soc 2018;52:204-9.

204 © 2018 Journal of Indian Orthodontic Society | Published by Wolters Kluwer ‑ Medknow

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Deshmukh and Vadera: En‑masse maxillary arch distalization with miniscrews

Table 1: Pretreatment cephalometric values

Parameter Value
SNA 82.7°
SNB 79.6°
ANB 3.1°
SN‑Go‑Gn 22.3° a
FMA 22.2°
1 to SN 99.1°
1 to NA (mm) 3.7 mm
1 to NB (mm) 2.4 mm
1 to Go‑Gn 93°
Esthetic plane Ls=−3.5 mm
Li=−0.7 mm
U6 – Pterygoid vertical (PtV) 16.0 mm b
Figure 1: (a) Pretreatment extraoral photographs of the patient showing
Treatment objectives a straight profile and a deep bite. (b) Pretreatment intraoral photographs
of the patient showing Class II division 2 malocclusion
These include
• Correction of deep bite and crowding
• Establishing a Class I molar and canine relationship
• Maintaining the facial profile.
After discussion with the patient, nonextraction
therapy with en‑masse distalization of the upper arch
for the correction of molar and canine relationships
using two miniscrews on either side of the arch was
a b
planned.
Both the arches were bonded with 0.022” MBT
prescription brackets. After initial leveling and alignment,
two miniscrews were placed between the roots of first
and second premolars and the second premolar and first
molar, respectively, on either side. With 0.019” × 0.025”
posted SS archwires in place, force was applied using
power chains. The first chain was placed from the distal c

screw to the canine hook and the second one from the Figure 2: (a) Pretreatment lateral cephalogram. (b) Digital tracing of the
pretreatment lateral cephalogram. (c) Pretreatment orthopantomogram
mesial screw to the posted hooks on both the sides.
The force on each chain was measured at 100 gm.
Hence, a total force of 200 gm was applied on either
side to carry out the distalization of the whole maxillary
dentition [Figure 3a and b]. a
After 8  months of distalization, Class  I molar and
canine relationships were achieved. Class II settling
elastics were worn by the patient during the finishing
stage [Figure 4].
The posttreatment cephalogram shows that a Class I
molar relation is achieved [Figure 5a]. The posttreatment
cephalogram and its superimposition with the b
pretreatment cephalogram are shown in Figure 5b. Figure 3:  (a) Intraoral photographs. Power chains from the miniscrews
for distalization. (b) Intraoral periapical radiographs showing the position
Table 2 depicts the posttreatment cephalometric values. of the miniscrews between the first and second premolars and between
the second premolar and first molar
Figure 5c shows the posttreatment OPG of the patient.
After finishing and debonding, the case shows a settled Case 2
Class I occlusion with an improvement in bite and smile An 11‑year‑old female patient reported to the clinic with
line [Figure 6a and b]. a chief complaint of forwardly placed teeth and a gummy

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Deshmukh and Vadera: En‑masse maxillary arch distalization with miniscrews

smile. Intraoral examination showed end‑on molar and of the patient does not show any evidence of third molars
canine relationships on both the sides with an overbite of in the upper arch [Figure 8c].
3.5 mm and an overjet of 5 mm. The upper arch showed
Treatment objectives
mild crowding, and there was a deep curve of Spee in the
These include
lower arch. The upper midline was deviated to the left by
• Correction of deep bite
2 mm. The upper and lower incisors were proclined. She
• Correction of proclination
had a convex profile with protrusive and hypotonic lips
• Establishing a Class I molar and canine relationship
[Figure 7a and b].
• Correcting the convex facial profile
Cephalometric analysis revealed a skeletal Class II • Correction of gummy smile.
relation with an ANB of 7.7° and a vertical growth
pattern [Figure 8a, b and Table 3]. The pretreatment OPG After evaluating the facial features and discussion
with the patient, nonextraction therapy with en‑masse
distalization and intrusion of the upper arch for the
Table 2: Posttreatment cephalometric values correction of end‑on molar and canine relationships using
Parameter Value two miniscrews on either side of the arch was planned.
SNA 82.9°
Although there was proclination of anterior teeth in
SNB 81.1°
both the arches, it was felt that in this particular case,
ANB 1.8°
SN‑Go‑Gn 21.4°
extractions would not benefit the patient’s facial features
FMA 18.3° and also the lips would remain protrusive.
1 to SN 110°
1 to NA (mm) 5.6 mm
1 to NB (mm) 3.6 mm
1 to Go‑Gn 101.2°
Esthetic plane Ls=−3.4 mm
Li=0.7 mm
U6 – Pterygoid vertical (PtV) 15.1 mm

a c

b
Figure 4: Intraoral photographs. Class II settling elastics during the Figure 5: (a) Posttreatment lateral cephalogram. (b) Superimposition
finishing stage of the pre‑ and posttreatment lateral cephalograms. (c) Posttreatment
orthopantomogram

a
a

b
Figure 6: (a) Posttreatment extraoral photographs of the patient showing
an improvement in smile line. (b) Posttreatment intraoral photographs
of the patient showing Class I molar and canine relationships and an
improvement in bite
b
Figure 7: (a) Pretreatment extraoral photographs of the patient showing
a convex profile with protrusive and hypotonic lips.  (b) Pretreatment
intraoral photographs

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Deshmukh and Vadera: En‑masse maxillary arch distalization with miniscrews

Table 3: Pretreatment cephalometric values

Parameter Value
SNA 86.2°
SNB 78.6°
ANB 7.7°
SN‑Go‑Gn 37.7°
FMA 33.5°
1 to SN 119.4°
1 to NA (mm) 5.6 mm a b
1 to NB (mm) 9.1 mm
1 to Go‑Gn 100.3°
Esthetic plane Ls=−0.1 mm
Li=2.7 mm
U6 – Pterygoid vertical (PtV) 18.7 mm

Both the arches were bonded with 0.022” MBT

c
prescription brackets. The treatment protocol with
miniscrews for this patient was different from the first Figure 8: (a) Pretreatment lateral cephalogram. (b) Digital tracing of the
pretreatment lateral cephalogram. (c) Pretreatment orthopantomogram
case as the patient exhibited a vertical growth pattern.
After initial leveling and alignment, two miniscrews were
placed between the roots of the second premolar and first
molar and the first and second molars, respectively, on
either side. With 0.019” × 0.025” posted SS archwires a
in place, power chains from the distal screw to the
canine hook and from the mesial screw to the posted
hooks on both the sides were attached. Again, a total
force of 200 gm was applied on either side to carry
out the distalization of the whole maxillary dentition
[Figure 9a and b].
Once the vertical control during distalization was b
achieved, the miniscrew between the first and second Figure 9: (a) Intraoral photographs. Power chains from the miniscrews for
molars was removed and placed between the first and distalization. (b) Intraoral periapical radiographs showing the position of
the miniscrews between the second premolar and first molar and between
second premolars on both the sides for more intrusive the first and second molars
effect on the anteriors [Figure 10a and b].
The distalization was complete in 8  months. The
treatment was completed with the canines and molars in
Class I relation.
a
The posttreatment cephalogram shows that a
Class I molar relation is achieved [Figure 11a]. The
posttreatment cephalogram and its superimposition with
the pretreatment cephalogram are shown in Figure 11b.
Table 4 depicts the posttreatment cephalometric values.
The posttreatment OPG shows the development of tooth
bud for the upper right third molar and the presence of
b
lower left and right third molars [Figure 11c].
Figure 10: (a) Intraoral photographs. Power chains from the miniscrews
The posttreatment extraoral photographs show a for more intrusive effect on the anteriors. (b) Intraoral periapical
radiographs showing the shifted position of the miniscrews between
reasonable correction of gummy smile [Figure 12a and b]. the first and second premolars and between the second premolar and
first molar
Discussion
Molar distalization in adults was initially considered forward movement of premolars and incisors.[7,8] With the
difficult to achieve without the potential side effects of help of miniscrews, distalization of the entire arch has

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Deshmukh and Vadera: En‑masse maxillary arch distalization with miniscrews

a c

b b
Figure 11: (a) Posttreatment lateral cephalogram. (b) Superimposition of Figure 12: (a) Posttreatment extraoral photographs of the patient showing
the pretreatment and posttreatment lateral cephalograms. (c) Posttreatment a reasonable correction of gummy smile. (b) Posttreatment intraoral
orthopantomogram photographs of the patient showing Class I molar and canine relationships

Table 4: Posttreatment cephalometric values miniscrews are used for distalization, two force vectors
Parameter Value are created which can be arranged on either side of the
SNA 86.2° Cres (front and behind) of the arch so that moment
SNB 79.3° components get canceled effectively. Simply put, when
ANB 6.9° a single force is applied to a long structure oriented
SN‑Go‑Gn 37.6° anteroposteriorly (dental arch), it has the effect of
FMA 32.5° tilting the arch at one end, while two forces on either
1 to SN 116.3° side of its center more efficiently lift the arch and
1 to NA (mm) 3.3 mm distalize it.
1 to NB (mm) 9.2 mm
1 to Go‑Gn 95.3° It is recommended that in a patient with a horizontal
Esthetic plane Ls=−1.5 mm growth pattern, as in the first case, the placement of the
Li=5.1 mm miniscrews should be between the first and the second
U6 – Pterygoid vertical (PtV) 18.0 mm premolars and the second premolar and first molar as
it causes effective distalization. In the second case
become possible with simultaneous retraction of incisors, with a vertical growth pattern, the miniscrews were
without the need to overcome round tripping. Single placed between the second premolar and first molar and
miniscrews have been used to achieve distalization, but between the first and second molars. This generated
studies have shown that force applied for distalization a higher vertical component of force in the region of
using a single miniscrew for anchorage may be the molars, thereby preventing their extrusion during
insufficient for effective distalization compared to the distalization. This helped in controlling the mandibular
plane angle.
use of two miniscrews. Furthermore, the magnitude and
direction of force vector given to the arch are better In the above‑mentioned cases, distalization with two
controlled with the use of two miniscrews. miniscrews corrected the molar and canine relationships
to Class I along with correction of incisor inclination
The center of resistance (Cres) of the maxillary dentition
and deep bite.
has been shown to be located around the middle area of the
premolar roots. The position of the miniscrew with respect During distalization, the status of the second molars and
to the Cres determines the magnitude and direction of force the posterior space distal to the first molar should be
vector and helps in achieving arbitrary arch rotation.[9] considered. In adolescent patients who are still growing,
the maxillary posterior area including the tuberosity
Jeon and Yu stated that more interproximal alveolar bone
continues to grow as the maxillary molars move distally.
is available between the maxillary second premolar and
Ricketts indicator for position of upper molar should be
first molar roots and between the maxillary first molar
taken into consideration to decide whether distalization
and second molar roots than in other locations.[3]
of upper molars is warranted. According to the indicator,
An intrusive force vector should accompany any the distal surface of upper first molar to PtV  (pterygoid
distalization, more so in high‑angle cases. When two vertical) should be equal to the sum of patient’s age

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Deshmukh and Vadera: En‑masse maxillary arch distalization with miniscrews
and 3 mm.[10] If the measured value on the cephalogram
is less, then distalization should not be attempted. In
addition, distal movement of maxillary molars in adults
has several limitations, such as presence of a strong
second molar (sometimes third molar also) and limited
tuberosity area. Extraction of third molars should be
considered before distal movement after carefully
inspecting the status of the second and third molars as
well as the maxillary tuberosity.[11]
The placement of two miniscrews on either side of
the arch to distalize the entire maxillary dentition is
quite technique sensitive. Both the miniscrews have
to be placed at a minimum of 60°–70° angulation, and
the distal miniscrew is recommended to be placed at
a higher level than the mesial miniscrew. This in the
authors’ experience has helped in seamless distalization
of the maxillary arch without the miniscrew interfering
with the roots of the maxillary teeth during distalization.
However, there always remains a possibility that
the roots may come in contact with the miniscrews,
thereby interfering with the distalization. If one comes
across such a situation, it is always prudent to shift
the position of the miniscrews so that distalization is
completed.
Critical appraisal – the mandibular lateral incisor
roots in the second patient should have been uprighted
[Figure 11c].
Conclusion
The resultant pattern of maxillary dentition during
distalization is closely associated with the relationship
between the center of resistance and the line of force.[9]
Appropriate placement of the miniscrews in the arch is
a key to effective and efficient en‑masse distalization of
the entire maxillary arch.
The placement of miniscrews in the first case with a
horizontal growth pattern was between the premolars and
the second premolar and the first molar. The placement
in the second case with a vertical growth pattern was
between the second premolar and first molar and the
first and second molars. This helped in controlling the
extrusion of the molars during distalization.
Journal of Indian Orthodontic Society  ¦  Volume 52  ¦  Issue 3  ¦  July-September 2018
Finally, it is important that the distalization of the arch
should be carried out within anatomic and biologic limits
of tooth movement.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patients have
given their consent for their images and other clinical
information to be reported in the journal. The patients
understand that their names and initials will not be
published and due efforts will be made to conceal their
identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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