CASE REPORT

Adult patient with mandibular protrusion

and unstable occlusion treated with titanium
screw anchorage
Yasuyo Sugawara,a Shingo Kuroda,a Nagato Tamamura,b and Teruko Takano-Yamamotoc
Okayama, Japan

Orthodontic treatment for adults can be difficult because they often have several problems, including some
associated with aging. This article reports the successful use of miniscrews to treat a 51-year-old woman
with Class III malocclusion, unstable occlusion, periodontal disease, and temporomandibular disorder. The
patient had a skeletal Class III jaw-base relationship, anterior and unilateral posterior crossbites, and a
deviated midline. It was therefore necessary to confirm her mandibular position with a stabilization splint.
Miniscrews were implanted in the retromolar area and used to move the mandibular teeth en masse distally.
After orthodontic treatment, the mandibular molars and anterior teeth were moved distally, and the patient
had a stable occlusion. Acceptable occlusion and periodontal health were maintained after 1 year of
retention. Our results suggest that miniscrews are useful for en-masse distal movement of mandibular teeth
in aging patients. (Am J Orthod Dentofacial Orthop 2008;133:102-11)

O
rthodontic treatment in adults is often difficult
because they have special considerations in
comprehensive treatment eg, many pros-
thetic restorations, missing teeth, periodontal problems,
and temporomandibular disorders (TMD).1 Gingivitis
and chronic periodontitis are the most common peri-
odontal diseases affecting adults.2 The periodontal situa-
tion sometimes causes undesirable tooth movement and
occlusal interference. As a result of this interference,
some patients are forced to change their mandibular
position. In these patients, orthodontic treatment is
required to establish adequate and stable occlusion. In
addition, it seems that the length of treatment is
increased in adult orthodontic patients.
In the treatment of adult Class III patients without
orthognathic surgery, various treatment methods have
been used, including multibrackets with Class III elas-
tics, extraction treatment, multiloop edgewise therapy,
and others.3-7 These techniques provide acceptable
interincisal relationships and stable occlusion; how-
From the Department of Orthodontics and Dentofacial Orthopedics, Graduate
School of Medicine, Dentistry and Pharmaceutical Science, Okayama Univer-
sity, Okayama, Japan.
a
Assistant professor.
b
Postgraduate student.
c and TMD.
Professor and chair.
Reprint requests to: Teruko Takano-Yamamoto, Department of Orthodontics
and Dentofacial Orthopedics, Graduate School of Medicine and Dentistry,
Okayama University, 2-5-1 Shikata-Cho, Okayama 700-8525, Japan; e-mail,
t_yamamo@md.okayama-u.ac.jp.
Submitted, April 2006; revised and accepted, June 2006.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.06.020
102
ever, most require intraoral or extraoral anchorage to
retract the mandibular incisors, and the quality of the
treatment results can depend on the patients coopera-
tion. In addition, it is difficult to achieve significant
distal movement of mandibular teeth with traditional
orthodontic mechanics.
Recently, implant anchorage has been effective for
treating a wide variety of adult malocclusions over a
lifetime.8 Dental implants, miniplates, and titanium
screws have been used for implant anchorage of orth-
odontic treatment.9-15 These materials can provide ab-
solute anchorage for tooth movement without the pa-
tients cooperation. In particular, miniscrews have
become mainstream for skeletal anchorage.16 Despite
their small diameter and short length, miniscrews can
obtain stable anchorage for various tooth movements
including intrusion, retraction, and protraction17-24;
however, there are few reports about miniscrews for
Class III adult patients with periodontal disease, unsta-
ble occlusion, and TMD.
In this report, we demonstrate the usefulness of
miniscrews in the retromolar area for en-masse distal
movement of the mandibular dentition in an older adult
Class III patient with jaw deviation, unstable occlusion,
DIAGNOSIS AND ETIOLOGY
A woman, 50 years 11 months of age, came to the
outpatient clinic of the dental hospital at Okayama
University in Japan (Figs 1-3). Her chief complaints
were anterior crossbite and unstable occlusion. How-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 1
Fig 1. Pretreatment photographs.
ever, she could achieve an edge-to-edge bite. A con-
cave profile due to mandibular excess was noted. Her
chin was deviated slightly to the right. Circumoral
musculature strain on lip closure was observed. Cross-
bite was observed in the anterior and unilateral poste-
rior teeth on the right side and in the premolars on the
left side. The mandibular anterior teeth had a slight
space, and the left lateral incisors were crowded. Facets
were observed in the maxillary right incisors and the
left central incisor. Overjet was 2.0 mm, and overbite
was 3.2 mm. The mesial roots of the left first molar and
the second molar were bridged after hemisection of the
distal root of the first molar. The maxillary dental
midline almost coincided with the facial midline, but
the lower midline was deviated to the right.
Periodontal pocket depth was from 2 to 3 mm.
Furthermore, the gingivae around the bridge showed
redness and slight swelling, and bleeding occurred after
Sugawara et al 103
probing. Horizontal bone resorption was observed in all
areas, and the mandibular anterior teeth were elongated.
There was some clicking in the right temporoman-
dibular joint (TMJ). A slight limitation of condylar
movement on the right side during opening and closing
was observed on a 6-degrees-of-freedom jaw move-
ment recording system (Gnathohexagraph system, ver-
sion 1.31; Ono Sokki, Kanagawa, Japan). On TMJ
tomography, the shape of the condyle was almost
normal; however, on magnetic resonance imaging of
the TMJ, the disc on the right side was displaced
anteriorly without reduction during opening-and-clos-
ing movements.
The cephalometric analysis, when compared with
the Japanese norm,25 showed a skeletal Class III
relationship (ANB angle, 4.7) with mandibular ex-
cess (SNB angle, 86.7). The mandibular body length
was long, but ramus height was within the normal range
104 Sugawara et al American Journal of Orthodontics and Dentofacial Orthopedics
January 2008

Fig 2. Pretreatment dental casts.

Fig 3. A, Pretreatment cephalograph and B, pretreatment cephalometric tracing (solid line)

superimposed on mean profilogram (dotted line); C, pretreatment panoramic radiograph.
American Journal of Orthodontics and Dentofacial Orthopedics Sugawara et al 105
Volume 133, Number 1

Table. Cephalometric summary

Variables Mean SD Pretreatment Posttreatment Postretention

Angular ()
ANB 2.8 2.4 4.7 2.6 2.8
SNA 80.8 3.6 82.0 82.0 82.0
SNB 77.9 4.5 86.7 84.6 84.8
Mp-FH 30.5 3.6 25.7 27.4 27.0
Gonial.A 122.1 5.3 120.7 121.0 121.0
U1-FH 112.3 8.3 115.5 124.0 124.0
L1-Mp 93.4 6.8 84.2 83.9 84.0
IIA 123.6 10.6 134.6 125.5 125.4
Occlusal.P 16.9 4.4 6.6 8.0 8.0
Linear (mm)
S-N 67.9 3.6 71.5 71.5 71.5
N-Me 125.8 5.0 127.1 128.5 128.3
Me/NF 68.6 3.7 73.9 74.7 74.5
Ar-Go 47.3 3.3 49.0 47.1 47.1
Ar-Me 106.6 5.7 115.8 114.0 114.0
OJ 3.1 1.1 2.0 2.0 2.0
OB 3.3 1.9 3.2 2.0 2.0
U1-NF 31.0 2.3 29.9 28.8 28.8
ABR-L6/Mp 17.9 2.6 26.2 20.5 20.5
L6-B/Mp 28.9 2.5 26.3 30.6 30.6
L6/Mp 32.9 2.5 36.1 36.4 36.4
L1/Mp 44.2 2.7 49.0 49.1 49.0

Fig 4. Intraoral photographs after stabilization splint.

(Go-Me, 81.0 mm; Ar-Go, 49.0 mm). The position and
size of the maxilla were almost average (SNA angle,
82.0). The mandibular incisors were lingually inclined
(L1-Mp angle, 84.2). Both maxillary and mandibular
molars showed anterior positioning (ABR-L6/Mp, 26.2
mm; L6-B/Mp, 26.3 mm; U6-A/NF, 22.9 mm; PTM-
U6/NF, 26.9 mm) (Table). The molar relationships
were Angle Class III on both sides. The mandibular
midline was deviated 2 mm to the facial and maxillary
midline.
that her mandibular position had changed with aging;
thus, it was necessary to confirm the proper mandibular
position. The treatment objectives were to confirm the
mandibular position, correct the anterior and posterior
crossbites and establish ideal overjet and overbite,
achieve a good functional Class I molar relationship,
and correct the deviation of the mandibular dental
midline. Therefore, we planned to use titanium screws
for anchorage to move the mandibular molars distally
and correct the dental midline.

TREATMENT OBJECTIVES TREATMENT ALTERNATIVES

The patient had the problems of an Angle Class III
malocclusion, with a skeletal Class III jaw base rela-
tionship, anterior and unilateral posterior crossbite,
lingual inclination of the mandibular incisors, and
deviation of the mandibular dental midline. She thought
The first alternative was orthognathic surgery. In
this option, the retroclined mandibular incisors would
be corrected to resolve crowding. Mandibular setback
could improve the underlying skeletal pattern, the
concave profile, and the mandibular body length; how-
106 Sugawara et al
Fig 5. Posttreatment photographs.
ever, we decided that the skeletal problem was not
sufficiently excessive to require orthognathic surgery.
The second alternative was orthodontic treatment
with tooth extraction. This procedure was explored to
correct the anterior crossbite and the deviation of the
dental midline, but the patient did not want tooth
extraction.
The third alternative was nonextraction treatment
with Class III intermaxillary elastics. This procedure
requires the patients cooperation and induces elonga-
tion of the mandibular anterior teeth. In addition, her
mandibular anterior teeth were not suitable for strain
because there was little alveolar bone support of these
teeth due to aging, and the patient did not want a
bothersome procedure. Moreover, Class III intermaxil-
lary elastics can impose a burden on an unstable
occlusion with TMD.
American Journal of Orthodontics and Dentofacial Orthopedics
January 2008
TREATMENT PROGRESS
It was necessary to confirm her improved mandib-
ular position, because she had an unstable occlusion
with premature incisor contact, so a stabilization splint
was placed on the maxillary arch. After 3 months, she
achieved an edge-to-edge occlusion when biting natu-
rally (Fig 4).
A preadjusted edgewise appliance with .018-in slots
was placed on the mandibular teeth after removing the
pontic. The mesial part of the first molar was moved
distally to close the space. The mandibular teeth were
aligned.
Titanium miniscrews (8 mm long, 1.3 mm in
diameter, Absoanchor; Dentos, Daegu, Korea), pro-
vided by Dr Hee-Moon Kyung of Kyungpook National
University, Korea, were implanted in the retromolar
area under local anesthesia. To apply upright force, a
American Journal of Orthodontics and Dentofacial Orthopedics Sugawara et al 107
Volume 133, Number 1

Fig 6. A, Posttreatment cephalograph and B, posttreatment tracing (solid line) superimposed on

mean profilogram (dotted line); C, posttreatment panoramic radiograph.

nickel-titanium coil spring was connected from the

miniscrews to the hook between the second premolar
and the first molar. They were loaded immediately after
placement with a force of 100 g.
After the overjet was corrected, a preadjusted edge-
wise appliance was also attached to the maxillary teeth.
Additionally, a nickel-titanium coil spring was applied
from the mandibular miniscrews to the hook between
the left second premolar and the first molar of the
mandible to improve the midline deviation.
The miniscrews were stable during treatment and
were removed under topical anesthesia. After debond-
ing and debanding, circumferential retainers were
placed in both arches. A lingual fixed retainer was also
bonded to the mandibular incisors. Total active treat-
ment time was 33 months. In the retention phase, the
left mandibular first and second molars were restored Fig 7. Superimposed pretreatment (solid line) and post-
with crowns. treatment (dotted line) cephalometric tracings. A, Su-
perimposed on sella-nasion plane at sella; B, superim-
TREATMENT RESULTS posed on palatal plane at ANS; C, superimposed on
A well-aligned dentition and a harmonious facial mandibular plane at menton.
balance were obtained (Figs 5 and 6). The facial profile
was improved by retracting the mandibular teeth. Mus- mandibular teeth. Furthermore, the dental midline cor-
cle strain of the mentalis and lower lip disappeared. responded between the maxilla and the mandible.
Canine and molar Class I relationships were achieved Cephalometric superimposition showed that the
with adequate overjet and overbite after retracting the ANB angle was increased from 4.7 to 2.6, and the
108 Sugawara et al
Fig 8. One-year postretention photographs.
SNB angle was reduced by 2.1. The mandibular
anterior teeth were retracted 2.0 mm without extrusion.
The mandibular first molar was straightened 5.1 mm,
achieving a normal position. The maxillary anterior
teeth were labially inclined (U1-FH, 124). The inter-
incisal angle decreased from 134.6 to 125.5. The
mandibular plane angle increased from 25.7 to 27.7
(Fig 7, Table).
The patient had an unstable occlusion with prema-
ture incisal contact at the first examination. After using
a stabilization splint, she achieved an edge-to-edge bite.
After treatment with a preadjusted edgewise appliance,
she was able to occlude naturally, and the deviation
improved. On cephalometric superimposition, the man-
dibular plane was rotated clockwise. After 1 year of
retention, acceptable occlusion and facial profile were
also maintained (Figs 8-10, Table).
American Journal of Orthodontics and Dentofacial Orthopedics
January 2008
DISCUSSION
Aging is inevitable, and oral conditions decline with
age.26 Adult patients tend to have special considerations in
comprehensive treatmentprosthetic restorations, miss-
ing teeth, periodontal problems, and TMD.1 Therefore,
orthodontic treatment for older adults is more difficult
than for children and adolescents. This patient also had
many problems peculiar to adults. She thought that her
mandibular position had changed with aging, and she
had an unstable occlusion with premature incisal con-
tact. The maxillary incisors had facets on the incisal
edges, and there was some clicking of the right TMJ. A
slight limitation of condylar movement was also ob-
served on the right side during opening-and-closing
movements. Therefore, we used a stabilization splint to
confirm a better mandibular position. After splint ther-
apy, she achieved an edge-to-edge bite. Then, we
American Journal of Orthodontics and Dentofacial Orthopedics Sugawara et al 109
Volume 133, Number 1

Fig 9. One-year postretention dental casts.

Fig 10. A, Postretention cephalograph and B, superimposed posttreatment (solid lines) and
postretention (dotted line) cephalometric tracing.

decided to move the mandibular teeth distally to re-
move occlusal interferences and to reconstruct an ideal
mandibular position.
In traditional orthodontic mechanics, we use the
space available by extraction of an anterior tooth or a
premolar and Class III elastics to retract the mandibular
teeth. Class III elastics can correct anterior crossbites
by retracting the mandibular anterior teeth lingually and
proclining the maxillary incisors labially; however, this
is counteracted by elongation of the mandibular inci-
sors and the maxillary molars, and also causes trans-
verse changes such as rotating the molar lingually.
Elongation of the maxillary molars increases lower
facial height. Furthermore, the patients cooperation is
110 Sugawara et al
essential for a successful treatment result. Recently,
implants have been used to achieve orthodontic anchor-
age.12,14,17,18,21,26 It is possible to move teeth in various
directions without the patients cooperation with im-
plant anchorage. In this patient, treatment with minis-
crews could prevent counteraction without her cooper-
ation and achieve distal movement of the mandibular
teeth en masse. In previous studies, miniplates were
often used for distal tooth movement and provided
adequate treatment results in Class III patients27; how-
ever, miniplates require flap surgery for both placement
and removal, with a longer healing period and more
pain and discomfort than titanium screws placed with-
out flap surgery.14 On the other hand, miniscrews can
be removed under topical anesthesia and do not require
sutures or postmedication. In this patient, the minis-
crews gave enough anchorage to move the mandibular
teeth distally. In addition, the success rates of
miniplates and miniscrews are not significantly differ-
ent14; therefore, distal movement with miniscrews is
simpler and more useful than with miniplates.
We previously reported a patient treated by using
titanium screws in the retromolar area as absolute
anchorage for molar mesialization.18 The retromolar
area is suitable for placing titanium screws because
there is sufficient bone mass and the probability of
contact with the dental root is low. In this patient, it was
possible to move the mandibular teeth more than 5 mm
distally, because miniscrews were not placed in the
alveolar part of the root area but outside the dental arch.
The patients facial profile was improved signifi-
cantly from concave to straight. Labial movement of
the maxillary incisors and lingual movement of the
mandibular incisors were closely related to forward
movement of the upper lip and backward movement of
the lower lip. Esthetic improvement was achieved
because the mandibular teeth moved distally with the
miniscrews. Furthermore, this patient had an unstable
occlusion with aging. We also achieved the proper
mandibular position by moving teeth distally using
miniscrews and obtained functional improvement. Re-
cently, we reported the successful treatment of a severe
anterior open bite with TMD using titanium screw
anchorage.21 After treatment, the TMD signs and
symptoms were reduced, occlusal force was increased,
and both function and occlusion were improved. There-
fore, we suggest that it might be useful to improve not
only the morphology, but also the function. Miniscrews
enlarge the range of orthodontic treatment options in a
patient with skeletal deformity and aging.
Retention in adults with periodontal disease, unsta-
ble occlusion, and TMD is difficult and important. In
this patient, acceptable occlusion was maintained after
American Journal of Orthodontics and Dentofacial Orthopedics
January 2008
1 year of retention. However, long-term stability after
treatment with implant anchorage has not yet been
reported. We need to increase our knowledge of reten-
tion in this area.
CONCLUSIONS
Miniscrews can be useful for en-masse distal move-
ment of mandibular teeth in older patients with TMD,
poor periodontal health, and unstable mandibular posi-
tion.
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