Journal of the World Federation of Orthodontists 6 (2017) 131e138

Contents lists available at ScienceDirect

Journal of the World Federation of Orthodontists

journal homepage: www.jwfo.org

Case Report

Maxillary arch distalization using interradicular miniscrews and the

lever-arm appliance: A case report
Mais M. Sadek*, Noha E. Sabet, Islam T. Hassan
Department of Orthodontics, Faculty of Dentistry, Ain Shams University, Cairo, Egypt

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

Article history: This case report shows the successful treatment of a patient with Class II Division 1 maxillary arch
Received 30 April 2017 distalization using the lever-arm appliance and interradicular miniscrews. A 15-year-old male patient
Received in revised form had a convex profile, a Class II malocclusion, increased overjet, and crowding in the upper and lower
7 June 2017
arches. Treatment was started with the placement of skeletal anchorage for distalization of the upper
Accepted 13 June 2017
arch. Miniscrews were implanted into the interradicular space between the maxillary second premolar
and first molar, and buccally at the mucogingival junction as well as on the palatal side. The lever-arm
appliance was used to bilaterally distalize the posterior segments in the upper arch. Leveling and
Keywords:
Distalization
alignment followed by retraction of the maxillary premolars, canines, and incisors were carried out to
miniscrews achieve normal overjet and relief of the crowding. Total treatment time for this patient was 24 months.
3D models Three-dimensional virtual maxillary models were acquired at pretreatment (T0) and posttreatment (T1)
using a three-dimensional laser scanning system. Models were superimposed using the surface 3-points
method and were used to evaluate treatment results in three dimensions. This report suggests that
interradicular miniscrews, together with the lever-arm appliance, are useful to allow three-dimensional
control while distalizing the maxillary molars for correcting a Class II malocclusion.
Ó 2017 World Federation of Orthodontists.

1. Introduction 2. Diagnosis and etiology

Skeletal Class II malocclusions are one of the most frequently
encountered malocclusions in the orthodontic practice. They are
often the result of protruded maxilla, retruded mandible, or a
combination. In growing patients, growth modification is often
attempted trying to achieve a harmonious relationship of the two
jaws. However, in adult patients with no growth potential, the
options are limited to either orthognathic surgery or orthodontic
camouflage. Various factors should be considered in treatment
planning, including the amount of discrepancy, the soft tissue
limitations, and profile treatment objectives [1].
Orthodontic camouflage for Class II malocclusions can be either
by extraction treatment or nonextraction treatment with dis-
talization of the entire maxillary arch to achieve the desired dental
and soft tissue treatment objectives.
In this case report, nonextraction treatment with distalization of
the entire maxillary arch for a 15-year-old male patient with skel-
etal Class II malocclusion is presented.
* Corresponding author: Orthodontic Department, Faculty of Dentistry, Ain
Shams University, Cairo 1156, Egypt.
E-mail address: maismedhat@asfd.asu.edu.eg (M.M. Sadek).
A 15-year-old male patient had a convex profile, a Class II
malocclusion, and increased overjet. He was in good general health
and had no history of major systemic disease or accident or history
of a thumb-sucking habit. His chief complaint was increased overjet
with crooked mandibular teeth.
Pretreatment facial photographs (Fig. 1A) showed that the pa-
tient had a convex soft tissue profile with a normal nasolabial
angle. From the frontal view, his face was slightly asymmetric, and
the chin was deviated slightly toward the right. Lip line while
smiling shows 50% of upper incisors and no gingival display; up-
per dental midline was coincident with the facial midline. The
smile appeared asymmetric, consonant, and with narrow buccal
corridors.
Intraoral and dental cast examinations (Fig. 1B) demonstrated a
Class II molar and canine relationship bilaterally. A 9.4-mm overjet
and 6.0-mm overbite were observed. Lower dental midline was
shifted to the left in relation to the upper midline; 4.5 mm of
anterior crowding in the maxillary arch and 7.0 mm of anterior
crowding in the mandibular arch were observed. A 1.5-mm
discrepancy in the Bolton tooth-size ratio with mandibular ante-
rior tooth excess was measured. The maxillary arch was relatively

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

http://dx.doi.org/10.1016/j.ejwf.2017.06.002
132 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138

Fig. 1. Pretreatment photos. (A) Extraoral photos; (B) intraoral photos.

narrow compared with the mandibular arch. No mandibular devi- constricted maxillary arch, (4) correct the midline deviation, (5)
ation or clicking noises were detected during opening or closing of obtain a stable occlusal relationship, and (6) ultimately improve his
his jaws. dental esthetics by establishing an esthetic smile.
Panoramic and lateral cephalometric radiographs were taken
before treatment (Figs. 2 and 3). The panoramic radiograph showed
2.2. Treatment alternatives
no caries, and all third molars were developing (Fig. 2). The ceph-
alometric analysis (Fig. 3; Table 1) demonstrated a Class II skeletal
The patient had a skeletal Class II relationship with mandibular
relationship (A point, nasion, B point, 5.2 ) with normal position of
retrusion. Orthognathic surgery with mandibular advancement,
the maxilla and retrusive position of the mandible in relation to the
combined with fixed orthodontic treatment, was discussed with
anterior cranial base. The patient had a normal growth pattern
the patient. Skeletal discrepancy correction, facial and dental
(Frankfort horizontal plane to mandibular plane, 27.8 ). The angle
esthetic change, and establishment of an ideal occlusion would all
between the maxillary incisors and the palatal plane was 124.6 ,
be possible with this surgical approach.
and the mandibular incisor to mandibular plane angle was 94.5 .
Fixed orthodontic treatment alone could retract the maxillary
Based on the findings, the patient was diagnosed as skeletal Class II
anterior teeth and create ideal overjet and overbite. For this pa-
with retrusive mandible, normal growth pattern, proclined upper
tient, both nonextraction and extraction were possible: (1) non-
incisors, and normal lower incisor inclination.
extraction with distalization of the entire maxillary arch to
achieve a Class I molar and canine relationship bilaterally with
2.1. Treatment objectives ideal overjet and overbite and gain space to correct crowding; or
(2) extraction of two upper premolars to gain space for the
The following treatment objectives were established: (1) create correction of crowding and retraction of the maxillary anterior
ideal overjet and overbite, (2) relieve the crowding, (3) correct the teeth.
 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138 133

Table 1
Cephalometric analysis

Measurement Norm Initial Final

SNA ( ) 82  2 80.8 80
SNB ( ) 80  2 75.6 75.5
ANB ( ) 22 5.2 4.5
A-Na Perp (mm) 0  3.1 1 1.3
Pg-Na Perp (mm) 4  5.3 6.2 7.2
Wits appraisal (mm) 01 4.4 0.1
Occlusal plane-FH ( ) 55 7.0 14.3
FH to MP ( ) 26  4 27.8 26.9
Palatal-MP ( ) 28  6 24.9 21.0
U1 to PP ( ) 110  5 124.6 111.1
L1 to MP ( ) 93  5 94.5 110.1
U1-PP (mm) 33  3 24.9 25.6
U6-PP (mm) 27.9  3 19.9 19.4
Fig. 2. Pretreatment panoramic radiograph. L6-MP (mm) 38  3 26.4 27.1

The patient and his parents declined orthognathic surgery as
well as orthodontic treatment with extractions. Because of this
response, the treatment plan included a nonextraction approach
with distalization of the entire maxillary arch.
ANB, A point, nasion, B point; FH, Frankfort horizontal; L1, lower central incisor;
MP, midpalatal; PP, palatal plane; SNA, sella nasion point A; SNB, sella nasion point B;
U1, upper central incisor; A-Na perp, Linear distance from point A to Nasion
perpendicular plane; Pg-Na perp, Linear distance from Pogonion to Nasion
perpendicular plane; U6, mesiobuccal cusp tip of upper first molar; L6, mesiobuccal
cusp tip of lower first molar.

2.3. Treatment progress
Before the treatment, the patient was referred to a periodontist
for a routine periodontal check-up. Treatment was started with the
placement of skeletal anchorage for distalization of the upper arch.
Miniscrews (1.6-mm diameter, 8.0-mm length; 3M Unitek, Mon-
rovia, CA) were implanted into the interradicular space between the
maxillary second premolar and first molar, and buccally at the
mucogingival junction as well as on the palatal side. Bands were
fitted on the first molars, and an impression was taken for a lever-
arm appliance. The appliance was constructed with a lever arm
extending from the molar band on the buccal and palatal sides so
that the retraction force would be applied parallel to the occlusal
plane (Fig. 4). The appliance was cemented and power chains
delivering 150 g of force extending from the miniscrews to the lever
arm buccally and palatally for both sides were used for maxillary
molar distalization.
After 4 months, distalization of both maxillary molars was
observed and adequate space could be seen mesial to the first
molars. After distalization, the buccal miniscrews were removed to
enable distal drifting of the premolars while the palatal miniscrews
were left in place to be used later to reinforce anchorage. At that
time, preadjusted 0.022  0.028-inch slot edgewise brackets (3M
Unitek) were bonded to the upper and lower arches, and bands for
the upper second molars and lower molars were cemented.
A 0.016-inch archwire and a 0.016  0.022-inch superelastic nickel-
titanium archwire (Dentsply GAC, Bohemia, NY) were used for the
initial leveling (Fig. 5). Interproximal reduction of 1.5 mm was
performed on the mandibular anterior teeth to eliminate the
discrepancy in the Bolton tooth-size ratio. The maxillary premolars
were drifted distally following the maxillary molar distalization. A
0.019  0.025-inch stainless steel wire was fitted to the upper and

Fig. 3. Pretreatment lateral cephalogram. Fig. 4. Lever-arm appliance.

134 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138

Fig. 5. (A) Treatment progress. After molar distalization, the palatal miniscrews were left in place to be used for indirect anchorage while leveling, alignment, and retraction were
achieved using preadjusted edgewise brackets. (B) Twelve months into treatment. Molar Class I relationship was achieved and premolars were drifted distally.

Fig. 6. (A) Superimposition of 3D pretreatment and posttreatment digital maxillary models. (B) Measurement of anteroposterior displacement (mm) of the maxillary first molars
and central incisors. (C) Measurement of maxillary first molar rotation. (D) Measurement of arch width variables. Intercanine width (ICW), distance between the cusp tip of right and
left maxillary canines; interfirst premolar width (IP1W), distance between the cusp tip of right and left maxillary first premolars; intersecond premolar width (IP2W), distance
between the cusp tip of right and left maxillary second premolars; interfirst molar width (IM1W), distance between the central fossae of right and left maxillary first molars.
 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138
Fig. 7. Posttreatment photos. (A) Extraoral photos; (B) intraoral photos.
lower arches, and the maxillary premolars, canines, and incisors
were retracted with indirect anchorage obtained from the palatal
miniscrews to achieve a Class I occlusion in the posterior segments,
relieve the anterior crowding, and achieve normal overjet and
overbite.
During the finishing stage, final detailing of the occlusion was
accomplished with 0.019  0.025-inch titanium-molybdenum
archwires (Dentsply GAC) in conjunction with vertical elastics
with Class II vectors (0.25 inch, 6 oz). A fixed retainer was attached
to the lingual surface of the maxillary and mandibular anterior
teeth. Overlaid Hawley retainers were fabricated and delivered to
secure the stability of both arches. Total treatment time for this
patient was 24 months.
2.4. Superimposition of maxillary dental models
Three-dimensional virtual maxillary models were acquired
at pretreatment (T0) and posttreatment (T1) using a three-
dimensional (3D) laser scanning system (D-750; 3Shape,
135
Copenhagen, Denmark). Using OrthoAnalyzer software (version
1.5; 3Shape), the T0 and T1 3D virtual models were superimposed
using the surface three-points method in which three corre-
sponding points are indicated on each model for alignment and
optionally select the surface to align the models (Fig. 6A). It has
been shown previously that the medial palatal rugae, in particular
the third medial rugae, can be used as a reference landmark for
assessment of tooth movement [2].
The midpoint of the incisal edge of the maxillary central incisors
and the mesiobuccal cusp tip of the first molars of the 3D virtual
maxillary model were used as reference points to measure tooth
movement. The three reference planes (horizontal, coronal, and
midsagittal planes of the 3D virtual maxillary models) were used to
carry out the linear and angular measurements on the digital models.
The horizontal plane was set at the uppermost region in the
midpalatal area, and was parallel to the occlusal plane. The coronal
plane was then set to be perpendicular to the horizontal plane and
was used to measure the anteroposterior displacement of the
maxillary central incisors and first molars on the superimposed
136 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138
models (Fig. 6B). This was measured as the distance between the
midpoint on the incisal edge of the upper central incisor and from
the central fossa of the first molar to the coronal plane. The
midsagittal plane was set to be perpendicular to the horizontal and
coronal planes passing through a midpoint between the maxillary
right and left central incisor edges. Rotation of the maxillary first
molars was measured as the angle between the line connecting the
mesial and distal triangular fossae of the first molar and the
midsagittal plane (Fig. 6C).
Transverse measurements included measurement of the inter-
canine width, distance between the cusp tip of right and left
maxillary canines; interfirst premolar width, distance between the
cusp tip of right and left maxillary first premolars; intersecond
premolar width, distance between the cusp tip of right and left
maxillary second premolars; and interfirst molar width, distance
between the mesiobuccal cusp tip of right and left maxillary first
molars (Fig. 6D).
3. Results
On the posttreatment facial photographs, a balanced facial
profile was achieved (Fig. 7A). The occlusion showed acceptable
intercuspation of the teeth, with Class I canine and molar re-
lationships, and normal overjet and overbite (3.0 mm and 3.1 mm,
respectively) (Fig. 7B). In the panoramic radiograph, proper root
parallelism is shown (Fig. 8). The posttreatment cephalometric
evaluation and cephalometric superimposition (Figs. 9 and 10)
showed a slight retraction of A point with reduction in the A point,
nasion, B point angle, as well as in the linear measurement of point
A to nasion perpendicular plane. The mandibular plane angle
decreased by 1 degree (mandibular plane to Frankfort horizonal
plane, 26.9 ) (Table 1). The inclination of the maxillary incisors was
corrected to be within the normal range (upper central incisor to
palatal plane, 111.1 ), and the lower incisors were proclined to help
relieve the crowding and camouflage the skeletal discrepancy. No
symptoms of temporomandibular disorder were observed
throughout active orthodontic treatment.
Superimposition of the pretreatment and posttreatment
maxillary models showed that the maxillary molars were bilaterally
distalized, and the upper incisors were retracted by 3.15 mm. The
maxillary first molars did not show any rotation during distaliza-
tion. Arch width variables showed some increase in the intercanine,
interfirst premolar, intersecond premolar, and interfirst molar
widths (3.19, 3.67, 4.69, and 2.57 mm, respectively).
4. Discussion
In this patient, premolar extractions were declined by the
patient and distal movement of the maxillary molars was
Fig. 8. Posttreatment panoramic radiograph.
required to treat the excessive overjet and relieve the crowding.
Conventional distalizing appliances using dental anchorage
often suffer from anchorage loss with significant proclination of
the maxillary incisors. Furthermore, a large percentage of the
acquired distalization is lost during the following phase of
retracting the maxillary dentition [3]. In this patient, the
second molars were fully erupted, and the use of skeletal
anchorage allowed distalization of the maxillary molars without
unwanted side effects. The palatal miniscrew was left in place to
be used for indirect anchorage while retracting the maxillary
anterior teeth. Interradicular screws were used, as they are
comfortable and do not need flap surgery for insertion or
removal. The interradicular site between the second premolar
and first molar was selected because this was recommended by
several studies as a suitable insertion site [4].
The lever-arm appliance allows good control in the three planes
for effective as well as efficient molar distalization (Fig. 11) [5]. In
the sagittal plane, it allows force application close to the center of
resistance of the molar to allow bodily distalization rather than
distal tipping (Fig. 11A). In the vertical plane, most intraoral dis-
talizers tend to extrude the maxillary molars during distalization,
thus increasing the mandibular plane angle. On the other hand, the
lever-arm appliance allowed adjustment of the vertical height of
the buccal as well as the palatal arm, producing simultaneous distal
and intrusive movement (Fig. 11A). In this patient, the mandibular
plane angle did not increase during active orthodontic treatment
but rather decreased by 1 degree. Furthermore, in the transverse
plane, force application from the buccal as well as the palatal side
provides good control on molar rotation (Fig. 11B). Finally, it can be
used either unilaterally or bilaterally.
In this patient, normal overjet and overbite were achieved with a
Class I canine and molar relationship using these mechanics. Space
gained through upper arch distalization allowed relief of upper arch
Fig. 9. Posttreatment lateral cephalogram.
 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138
Fig. 10. Cephalometric superimposition at pretreatment (black) and posttreatment
(green). (A) Overall superimposition. (B) Maxillary regional superimposition.
(C) Mandibular regional superimposition.
crowding as well as incisor retraction and improvement of upper
incisor inclination. Wits value decreased from 4.4 mm to 0.1 mm;
this could be in part related to the change in occlusal plane angle
137
Fig. 11. Diagram of the lever-arm and mini-implant system for upper molar distal
movement. LAb, buccal lever arm; LAp, palatal lever arm; MI, mini-implant; DFb, line of
action of the distal force on the buccal side; DFp, line of action of the distal force on the
palatal side; MFb, moment of distal force on the buccal side; MFp, moment of force on
the palatal side; CR, center of resistance of the upper molar. (A) The line of action of the
distal force passes through the center of resistance of the upper molar with an
intrusive component. (B) Application of the distal force on both the buccal and palatal
sides facilitates the rotational control of the upper molar during distal movement.
from 7.0 to 14.3 . However, the lower incisors were proclined at the
end of treatment to help relieve the lower arch crowding and
camouflage the skeletal discrepancy. This also contributed to overjet
reduction. A fixed retainer was used to ensure adequate stability.
Good vertical control was achieved with a reduction in
mandibular plane and palatal-mandibular plane angle. This was the
result of the intrusive force vector applied during distalization (U6
to palatal plane decreased from 19.9 mm to 19.4 mm).
Superimposition of 3D models using OrthoAnalyzer software
allowed adequate visualization and quantification of treatment ef-
fects. Traditionally, tooth movement was evaluated by cephalometric
superimposition, which is limited to two-dimensional evaluation.
Three-dimensional evaluation of treatment results using superim-
position of digital models further enhances accuracy and minimizes
errors. The various linear and angular variables allow accurate
measurements in the anteroposterior, vertical, and transverse planes.
The palatal rugae have always been recommended for accurate
registration of maxillary models. Bailey et al [6] studied the potential
use of palatal rugae for superimposition of serial models and
concluded that specific parts of the palatal rugae may be sufficiently
stable to serve as anatomic references for superimposition of serial
maxillary models. Jang et al [7] evaluated the stability of palatal
138 M.M. Sadek et al. / Journal of the World Federation of Orthodontists 6 (2017) 131e138
rugae using digital models superimposed on three miniscrews as
registration landmarks and concluded that the medial points of the
third palatal rugae and the shape of the palatal vault were stable
throughout orthodontic treatment with premolar extraction.
In our patient, using OrthoAnalyzer software, a surface three-
point method was used for superimposition of pre- and posttreat-
ment maxillary models. This method entails identifying three
points on the palatal rugae in both models, as well as the best-fit
method using the palatal surface for accurate superimposition of
serial 3D digital models.
5. Conclusion
This case report demonstrates that interradicular miniscrews,
together with the lever-arm appliance, can be successful in
providing 3D control while distalizing the maxillary molars for
correcting a Class II malocclusion.
References
[1] Proffit WR, Fields WH, Sarver DM. Orthodontic treatment planning:
limitations, controversies, and special problems. In: Proffit WR, Fields WH,
Sarver DM, editors. Contemporary orthodontics. St. Louis: Mosby; 2007.
p. 295e9.
[2] Hoggan BR, Sadowsky C. The use of palatal rugae for the assessment of ante-
roposterior tooth movements. Am J Orthod Dentofacial Orthop
2001;119:482e8.
[3] Grec RH, Janson G, Branco NC, Moura-Grec PG, Patel MP, Castanha Henriques JF.
Intraoral distalizer effects with conventional and skeletal anchorage: a meta-
analysis. Am J Orthod Dentofacial Orthop 2013;143:602e15.
[4] Park J, Cho HJ. Three-dimensional evaluation of interradicular spaces and
cortical bone thickness for the placement and initial stability of microimplants
in adults. Am J Orthod Dentofacial Orthop 2009;136:314.e1e314.e12.
[5] Lim SM, Hong RK. Distal movement of maxillary molars using a lever-arm and
mini-implant system. Angle Orthod 2008;78:167e75.
[6] Bailey LT, Esmailnejad A, Almeida MA. Stability of palatal rugae as landmarks for
analysis of dental casts in extraction and nonextraction cases. Angle Orthod
1996;66:73e8.
[7] Jang I, Tanaka M, Koga Y, et al. A novel method for the assessment of three-
dimensional tooth movement during orthodontic treatment. Angle Orthod
2009;79:447e53.