[Link].

mx

Revista Mexicana de Ortodoncia

Vol. 6, No. 2 April-June 2018
pp 96-102 CASE REPORT

Corrective treatment of a moderate class I bimaxillary

dentoalveolar protrussion: bimaxillary dentoalveolar
distalization with mini-screws
Tratamiento correctivo de protrusión dentoalveolar bimaxilar clase I
moderada: distalización dentoalveolar bimaxilar con miniimplantes
Francisco Shamed Méndez Ordóñez,* Gisel García García,§
Roberto Ruíz Díaz,§ Isaac Guzmán Valdivia Gómez||

ABSTRACT RESUMEN

There are several ways to treat biprotrusive class I and they are Existen diversas formas de tratar las clase I biprotrusivas y és-
directly related to the severity of the case. The most common form tas van a estar directamente relacionadas con la severidad del
of treatment includes the extraction of maxillary and mandibular caso. La forma más común de tratamiento incluye la extracción
first premolars, as well as retraction of the anterior segment to de los primeros premolares maxilares y mandibulares, así como
reduce bimaxillary biprotrusion. A new treatment alternative for la retracción del segmento anterior para disminuir la biprotrusión
this kind of malocclusion is bimaxillary distalization with the use bimaxilar. Una nueva alternativa de tratamiento para este tipo de
of mini implants, which in addition to guaranteeing a maximum maloclusiones puede ser la distalización bimaxilar con el uso de
anchorage will allow us to move multiple teeth in a single direction miniimplantes, lo cual además de garantizarnos un máximo an-
with controlled movements. Material and methods: Four mini- claje nos permitirá mover múltiples dientes en una sola dirección
implants were placed for maximum anchorage (two 10 mm infra- con movimientos controlados. Material y métodos: Se colocaron
cygomatic mini-implants and two 12 mm mini implants in the cuatro miniimplantes como anclaje máximo (dos infracigomáticos
mandibular shelf) to perform a bimaxillary distalization. Passive de 10 mm y dos en el shelf mandibular de 12 mm) para realizar
self-ligating brackets were placed with elastic chains to perform una distalización bimaxilar, se colocaron brackets de autoligado
mass distalization of both arches. Results: Mini implants proved to pasivo y apoyados en cadenas elásticas se realizó la distalización
be an efficient alternative for the correction of moderate bimaxillary en masa de ambas arcadas. Resultados: Los miniimplantes de-
protrusion; distalization was performed until molar class I and mostraron ser una alternativa eficiente para la corrección de una
canine class I on both sides was obtained, as well as a normal protrusión bimaxilar moderada, la distalización se realizó hasta
overjet and overbite. Among the esthetic facial changes achieved conseguir una adecuada clase I molar y clase I canina en ambos
was a decrease in the biprochelia. Conclusions: Treatment of lados, así como una sobremordida horizontal y vertical adecuada,
biprotrusive class I will depend on the severity of the case but mini los cambios estéticos faciales fueron una disminución de la bipro-
implants prove to be an interesting option for the treatment of this quelia. Conclusiones: El tratamiento de la clase I biprotrusiva
kind of malocclusion. dependerá de la severidad del caso, los miniimplantes demues-
tran ser una opción interesante para el tratamiento de este tipo de
maloclusiones.

Key words: Bimaxillary distalization, mini-implants, bimaxillary protrusion.

Palabras clave: Distalización bimaxilar, miniimplantes, protrusión bimaxilar.

INTRODUCTION
[Link] *
§
Student of the Orthodontics Specialty.
Professor of the Orthodontics Specialty.
||
Head of the Orthodontics Specialty.
Biprotrusive skeletal class I is a condition in which
Odontology Faculty, Division of Post-Graduate Studies and
the maxilla and the mandible are in an adequate Research of the Odontology Faculty, UNAM.
intermaxillary relationship but both are found
ahead of the skull base. 1 Bimaxillary protrusion is © 2018 Universidad Nacional Autónoma de México, [Facultad de
characterized by proclination of the anterior teeth Odontología]. This is an open access article under the CC BY-NC-ND
license ([Link]
and convexity in the patient’s profile; this can occur
in any ethnic group, although it is more common in This article can be read in its full version in the following page:
African-American and Asian patients. 1 The etiology [Link]
Revista Mexicana de Ortodoncia 2018;6 (2): 96-102
97

of bimaxillary protrusion is multifactorial and may be MATERIAL AND METHODS

associated with genetic, environmental, and habit
factors (mouth breathing, tongue and lip habit, and 23-year-old male patient who attended the
tongue size).2 Orthodontic Clinic of the Department of Postgraduate
Treatment of bimaxillary protrusion can be Studies and Research of the National Autonomous
successfully resolved with orthodontics, surgery, or a University of Mexico, campus Ciudad Universitaria
combination of surgery and orthodontics. Orthodontic (DEPeI, UNAM, C.U.) to receive treatment.
treatment includes the removal of the first premolars Uponclinical examination no pathological lesions
(upper and lower), the retraction of the anterior were observed. A cephalometric diagnosis was
segment with maximum anchorage in order to reduce performed and the following information was obtained:
dentoalveolar protrusion.3-5 biprotrusive skeletal class I patient with neutral growth,
Unfortunately, there are patients who do not want mesofacial biotype, convex profile, no coincidence of
to have premolar extractions, so the protrusion dental and facial midlines; edge to edge bite, bilateral
reduction and improvement in facial aesthetics molar class I and bilateral canine class I, moderate
that would lead to the success of treatment will crowding in upper and lower arch, lower incisor
be compromised. Because of this it is of great proclination, protrusion of upper and lower incisors
importance to know other treatment alternatives that (Figures 1 to 3).
allow us to achieve our goals while respecting the The initial treatment plan indicated the removal of
patient’s decisions. the maxillary and mandibular first premolars. In view
Considering that every orthodontic movement of the patient’s refusal to accept extractions, it was
is accompanied by a reaction (Newton’s first law), decided to place four mini-implants (two infracigomatic
it may be difficult to correct a malocclusion simply and two in the mandibular shelf) to perform an en
by using intraoral devices, 6 especially when it is masse distalization of the upper and lower arches.
necessary to perform an en masse movement
of all teeth or a group of them in both the maxilla Objectives
and mandible, which will increase our demands for
anchorage. Among the objectives established during treatment
There are several articles in the literature that there are:
describe dentoalveolar distalizations of the maxilla
in class II patients and of the mandible in class III • Bimaxillary distalization with mini implants.
patients using temporary anchorage devices (TADS) • Eliminate crowding.
which, among their advantages, offer us maximum • Maintain molar and canine class I.
anchorage, little cooperation from the patient and no • Achieve a normal overjet and overbite.
loss of anchorage. • Coordinate arches.
Kuroda in 2005 reported the use of temporary • Achieve root parallelism.
skeletal anchorage devices for the treatment of class • Closure of spaces.
III adult patients, and suggested that such devices • Retention.
can be placed in the retromolar area or between
tooth roots for direct or indirect mass distalization Treatment plan
in the lower arch. 7 In 2013 Ishida et al. reported
the case of a patient with class II malocclusion who Placement of H4® fixed appliances; 0.022 ” x 0.028” slot
was corrected with an asymmetric distalization of (1300 Alfa Dr. NE McMinnville, Oregon), with bondable
[Link]
the upper molars using mini-implants placed in the
zygomatic arch thus distalizing the entire dentition.8
tubes in first and second upper and lower molars.
Placement of Dewimed ® mini-implants (Blvd.
Tai et al. also reported the case of a patient with Adolfo Ruíz Cortines No. 5271, Del Tlalpan, Isidro
class III malocclusion who had the mandibular Fabela, Mexico City), two in the upper arch of 10 mm
dentition moved distally with temporary skeletal (infracigomatic) and two in the lower arch of 12 mm
anchorage devices.9 (mandibular shelf).
This article reports the clinical case of a 23-year-old Immediate loading after mini-implant placement.
skeletal class I male patient with moderate biprotrusion
who was successfully corrected through bimaxillary Phase I: alignment and leveling.
dentoalveolar distalization using mini implants as • 0.014”, 0.016”, 0.018”, 0.014” x 0.025” 0.016” x
anchorage devices. 0.025” NiTi archwires.
 Méndez OFS et al. Corrective treatment of a moderate class I bimaxillary dentoalveolar protrussion
98

Figure 1.

Initial facial and

intraoral
photographs.

Phase II: arch coordination and space closure. normal overjet and overbite; obtain root parallelism
• 0.017” x 0.025” NiTi; 0.017 x 0.025” stainless steel, (Figures 4 to 7).
0.019” x 0.025” NiTi, 0.019 x 0.025” stainless steel On an aesthetic level, a good smile was achieved,
archwires. as well as a decrease in the lip protrusion and an
• Panoramic radiograph for bracket repositioning. improvement in the patient’s profile.
Cephalometrically, skeletal class I was
Phase III: detailing and occlusal settlement. preserved, bimaxillary protrusion was reduced and

elastics for settlement.

[Link]
• 0.019” x 0.025” SS braided archwire, ¼ medium some cephalometric measurements were improved
(Table I).
• Bracket removal and placement of circumferential
retainers. DISCUSSION

RESULTS Among the clinical characteristics of skeletal class

I with bimaxillary protrusion we may find a molar and
At the end of treatment, the objectives set at the canine class I, presence or not of crowding, as well
beginning were fulfilled: to maintain bilateral I molar as a moderate or severe lip protrusion. Treatment
and canine class; distalize to obtain space and thus may have multiple options and will be directly related
eliminate crowding; match dental midlines; achieve a to the severity with which each case is diagnosed.
Revista Mexicana de Ortodoncia 2018;6 (2): 96-102
99

Figure 2.

Initial study models.

A B

Figure 3.
[Link] Initial radiographs and cephalometric tracing.
A. Lateral headfilm. B. Cephalometric tracing.
C
C. Panoramic radiograph.

Each patient will present unique characteristics premolars, orthognathic surgery, orthognathic and
and therefore, the various ways of approaching and orthodontic surgery or the use of mini implants to
treating each particular case must be known. perform bimaxillary distalizations.
Among the forms of treatment that we may find to With the surge of mini implants, it is now possible to
treat this kind of cases there are: extractions of first perform en masse or group dental movements using
 Méndez OFS et al. Corrective treatment of a moderate class I bimaxillary dentoalveolar protrussion
100

the benefits of absolute anchorage. Traditionally, In one way or another the use of these appliances
distalization of a tooth or group of teeth after eruption almost always required very good cooperation from
of the second molars becomes an absolute challenge. the patient, so the treatment result did not depend
Over the years, headgears and pendulums have been directly on the orthodontist. Thanks to new interest
used to achieve the distalization of one or more teeth.10,11 in temporary anchorage systems, we can achieve
satisfactory results where patient cooperation is not
so much required and the orthodontist can have better
Table I. Cephalometric values pre
control of the case.
and post-bimaxillary distalization.
To achieve a successful bimaxillary distalization,
Measurement Norm Pretreatment Postreatment three factors must be considered: 1) mini implant
placement, which must be in the cortical bone and at an
SNA 82o ± 2o 89o 88o adequate distance from the roots. The infracigomatic
SNB 80o ± 2o 86o 85o crest in the maxilla, 8 the mandibular shelf and/or
ANB 2o 3o 3o retromolar area in the mandible12,13 appear to be the
1 vs 1 125o ± 5o 132o 129o appropriate areas for the placement of mini implants.
1-SN 102o ± 2o 110o 108o
2) The absence of third molars to take advantage of
1-ENA-ENP 106o ± 6o 114o 110o
IMPA 90o ± 3o 96o 93o the space in the posterior areas for distalization and 3)
the patient’s growth direction.

[Link]

Figure 4.

Final facial and

intraoral photographs.
Revista Mexicana de Ortodoncia 2018;6 (2): 96-102
101

CONCLUSIONS moderate skeletal class I bimaxillary protrusion without the

need to perform extractions of the upper and lower first
This case demonstrates that mini implants can be premolars, always remembering that the type and plan of
an effective alternative for the corrective treatment of a treatment will be directly related to the severity of the case.

Este documento es elaborado por Medigraphic

Figure 5.

Final study models.

[Link]
A B

Figure 6.

Final radiographs and

cephalometric tracing. A. Lateral
C
headfilm. B. Cephalometric
tracing. C. Panoramic radiograph.
 Méndez OFS et al. Corrective treatment of a moderate class I bimaxillary dentoalveolar protrussion
102

5. Aljhani A, Zawawi KH. The use of mini-implants in en masse

Color image available at: [Link]/ortodoncia

retraction for the treatment of bimaxillary dentoalveolar

protrusion. Saudi Dent J. 2010; 22 (1): 35-39.
6. Chung KR, Kim SH, Choo H, Kook YA, Cope JB. Distalization of
the mandibular dentition with mini-implants to correct a Class III
malocclusion with a midline deviation. Am J Orthod Dentofacial
Orthop. 2010; 137 (1): 135-146.
7. Kuroda S, Sugawara Y, Yamashita K, Mano T, Takano-
Yamamoto T. Skeletal Class III oligodontia patient treated with
titanium screw anchorage and orthognathic surgery. Am J
Orthod Dentofacial Orthop. 2005; 127 (6): 730-738.
8. Ishida T, Yoon HS, Ono T. Asymmetrical distalization of maxillary
molars with zygomatic anchorage, improved superelastic
nickel-titanium alloy wires, and open-coil springs. Am J Orthod
Dentofacial Orthop. 2013; 144 (4): 583-593.
9. Tai K, Park JH, Tatamiya M, Kojima Y. Distal movement of the
mandibular dentition with temporary skeletal anchorage devices
Before treatment November 2015 to correct a Class III malocclusion. Am J Orthod Dentofacial
After treatment March 2017 Orthop. 2013; 144 (5): 715-725.
10. Toy E, Enacar A. The effects of the pendulum distalising
Figure 7. Superimposition. appliance and cervical headgear on the dentofacial structures.
Aust Orthod J. 2011; 27 (1): 10-16.
11. C a p r i o g l i o A , B e r e t t a M , L a n t e r i C . M a x i l l a r y m o l a r
distalization: Pendulum and Fast-Back, comparison between
REFERENCES two approaches for Class II malocclusion. Prog Orthod. 2011;
12 (1): 8-16.
1. Chen G, Teng F, Xu TM. Distalization of the maxillary and 12. Anhoury PS. Retromolar miniscrew implants for Class III
mandibular dentitions with miniscrew anchorage in a patient camouflage treatment. J Clin Orthod. 2013; 47 (12): 706-715.
with moderate Class I bimaxillary dentoalveolar protrusion. Am 13. Poletti L, Silvera AA, Ghislanzoni LT. Dentoalveolar class III
J Orthod Dentofacial Orthop. 2016; 149 (3): 401-410. treatment using retromolar miniscrew anchorage. Prog Orthod.
2. Lamberton CM, Reichart PA, Triratananimit P. Bimaxillary 2013; 14: 7.
protrusion as a pathologic problem in the Thai. Am J Orthod.
1980; 77 (3): 320-329.
3. Solem RC, Marasco R, Guiterrez-Pulido L, Nielsen I, Kim
SH, Nelson G. Three-dimensional soft-tissue and hard-tissue
changes in the treatment of bimaxillary protrusion. Am J Orthod
Dentofacial Orthop. 2013; 144 (2): 218-228.
4. Ouyang L, Zhou YH, Fu MK, Ding P. Extraction treatment of an
adult patient with severe bimaxillary dentoalveolar protrusion Mailing address:
using microscrew anchorage. Chin Med J (Engl). 2007; 120 (19): Francisco Shamed Méndez Ordóñez
1732-1736. E-mail: [Link]@[Link]

[Link]