CLINICIAN’S CORNER

Occlusal plane change after intrusion of

maxillary posterior teeth by microimplants to
avoid maxillary surgery with skeletal Class III
orthognathic surgery
Hyo-Sang Park,a Ji-Yeun Kim,b and Tae-Geon Kwonc
Daegu, Korea

Introduction: To increase stability and mandibular setback movement, surgical maxillary impaction is nor-
mally performed with mandibular setback surgery in treating adult skeletal Class III patients. This article dem-
onstrates the use of microimplants for anchorage to intrude molars and the resultant rotation of the maxillary
occlusal plane clockwise to increase the surgical mandibular setback and reduce the posterior vertical dimen-
sion instead of maxillary surgical impaction. Methods and Results: A 21-year-old man with mandibular
prognathism was treated with mandibular setback surgery that included orthodontic treatment for decompen-
sation. Microimplants placed into the palatal alveolar bone between the maxillary first and second molars were
used to intrude the maxillary posterior teeth and change the occlusal plane clockwise. This produced 4 mm
more of distal movement of the chin during mandibular setback surgery compared with the surgical prediction
with no change in the occlusal plane. These results were similar to those of 2-jaw surgery with maxillary pos-
terior impaction. Conclusions: The intrusion of the maxillary posterior teeth with microimplants might prevent
the need for maxillary surgery in adult skeletal Class III patients. (Am J Orthod Dentofacial Orthop
2010;138:631-40)

S
keletal anchorage has made it possible to correct mandibular skeletal changes by auto-rotation of the
malocclusions that were impossible to correct mandible after intrusion of the molars in open-bite treat-
with conventional orthodontic mechanics. The ment.12 With the aid of microimplants, clinicians can
use of microimplants1-4 has increased over other move teeth exactly to the goal.
skeletal anchorage systems, dental implants,5 and mini- The first treatment option for an adult with a skel-
plates,6 thanks to their low-cost, easy surgical placement etal Class III malocclusion is orthognathic surgery,
and removal, and few anatomic limitations. Because of which consists of 2-jaw or 1-jaw mandibular surgery.
their small size, they can be placed between the roots The presurgical orthodontic treatment is basically a de-
of the teeth. compensation process to align and level the teeth
Microimplants can provide anchorage for en-masse properly in relation to the jaw bones. The position of
retraction of the anterior tooth segments3,4,7 and the teeth in the conventional technique can be controlled
whole arch,8 intrusion of 1 tooth or more,9 and protrac- mainly by extraction of teeth and partly by the pa-
tion of the molars.10 Furthermore, microimplants might tient’s compliance in using extraoral anchorage de-
bring about skeletal changes after surface bone resorp- vices. However, with microimplants, we clinicians
tion after bodily retraction of anterior teeth11 and can control tooth movement precisely and 3 dimen-
sionally. The anteroposterior or vertical position of
From the School of Dentistry, Kyungpook National University, Daegu, Korea. the anterior or posterior teeth can be controlled by mi-
a
Professor, Department of Orthodontics. croimplants. Control of the maxillary occlusal plane in
b
Postgraduate student, Department of Orthodontics.
c
Associate professor, Department of Oral and Maxillofacial Surgery. patients with facial asymmetry could eliminate the
need for maxillary jaw surgery.13 Control of the occlu-
sal plane in an anteroposterior direction could change
the distal movement of the proximal segment in man-
dibular setback surgery, and this could enhance the
profile improvement. Here, we describe a patient
whose teeth were positioned in a proper position rela-
tive to the jaw base with microimplant anchorage and
632 Park, Kim, and Kwon American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Fig 1. Pretreatment records.

discuss the effect of maxillary molar intrusion on the Table. Cephalometric measurements
amount of mandibular setback surgery. Pretreatment Before surgery Posttreatment

DIAGNOSIS AND ETIOLOGY SNA ( ) 83 83 83

SNB ( ) 88 88.5 81
A 21-year-old man with mandibular prognathism ANB ( ) –5 –5.5 2
came for treatment (Fig 1). He had a Class III sagittal NaP-A (mm) 3.4 2.7 1.5
skeletal relationship with a concave profile. The etiol- NaP-Pog (mm) 16.8 17.8 2.6
ogy of mandibular prognathism was assumed to be Co-A (mm) 91.7 90.5 89.3
Co-Gn (mm) 130.4 140 120
overgrowth of the mandible; the SNB angle was 88 ,
ANS-Me (mm) 72 71.2 71
the position of pogonion relative to the nasion- FMA ( ) 19 18.5 25.5
perpendicular was 16.8 mm (normal range, –2 to 14 mm), PFH/AFH 53/71.5 (0.74) 51/71.5 (0.71) 44/70.5 (0.62)
and the distance from condylion to anatomic gnathion FH to OP ( ) –2.8 0.8 3.5
was 130.4 mm (normal value, 119.4 6 5.3 mm) FH to UI ( ) 140.5 127.5 128.5
IMPA ( ) 84 83 78.5
(Table). The FMA was 23 , and the lower facial height
Z-angle ( ) 87 82.5 82.5
was 64.3 mm. The nasolabial angle was 80 . The Nasolabial angle ( ) 80 87 100
patient’s vertical skeletal proportions were normal, Upper lip to E (mm) –3 –4.8 –2
and there was no facial asymmetry. Lower lip to E (mm) 2.8 5.5 –1
Intraorally, the patient had Class III canine and mo- NaP-A, horizontal distance of A to nasion perpendicular line;
lar relationships (Figs 1 and 2). He had –4 mm of overjet NaP-Pog, horizontal distance of pogonion to nasion perpendicular
and 0 mm of overbite. Both maxillary and mandibular line; PFH/AFH, posterior facial height/anterior facial height.
American Journal of Orthodontics and Dentofacial Orthopedics Park, Kim, and Kwon 633
Volume 138, Number 5

Fig 2. Pretreatment digital dental casts.

midlines were coincident with the patient’s facial was necessary to obtain facial esthetics and normal
midline. The maxillary anterior teeth were proclined occlusion. Presurgical orthodontic treatment would in-
(angle of the maxillary incisors to Frankfort horizontal clude extraction of the maxillary first premolars, align-
[FH] plane, 140.5 ), and the mandibular anterior teeth ment of the crowded anterior teeth, linguoversion of
were retroclined (angle of the mandibular incisors to the maxillary anterior teeth, and labioversion of the
the mandibular plane, 84 ). This showed dentoalveolar mandibular anterior teeth.
compensation for the sagittal skeletal discrepancy. The The second alternative was 2-jaw surgery with
cant of occlusal plane to the FH plane was –2.8 . clockwise rotation of the maxillary occlusal plane
Arch-length discrepancies in the maxillary and mandib- (jaw rotation). Surgical impaction of the maxillary pos-
ular arches were –2 and –4.5 mm, respectively. There terior segment reduces the posterior vertical dimension
was no apparent transverse discrepancy. or maintains the vertical length of the masseteric ring;
these movements enhance posttreatment stability.
TREATMENT OBJECTIVES Impaction of the maxillary posterior segment also
Five treatment objectives were identified: (1) correct increases the surgical mandibular setback movement.
the mandibular prognathism, (2) balance the position of The third treatment option was mandibular 1-jaw
the upper lips after positioning the maxillary anterior surgery after control of the tooth positions 3 dimension-
teeth properly relative to the maxilla, (3) change the ally with microimplants. Clockwise rotation of the max-
occlusal plane in a clockwise direction by intruding illary occlusal plane after intrusion of the maxillary
the maxillary posterior teeth about 2 mm to increase posterior teeth can cause clockwise rotation of the distal
the surgical mandibular setback movement, (4) estab- segment of the mandible during mandibular setback sur-
lish functional occlusion with normal overbite and gery. Intrusion of the maxillary posterior teeth can be
overjet, and (5) resolve crowding. performed easily and efficiently with microimplants.
This orthodontic procedure can eliminate maxillary
TREATMENT ALTERNATIVES surgery. The ease of the surgical procedure and the ex-
The first treatment option was mandibular setback pected good treatment effects led the patient to choose
surgery. Surgical setback movement of the mandible this option.
634 Park, Kim, and Kwon American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Fig 3. Treatment progress. The intrusion force was applied to the maxillary posterior teeth from
maxillary microimplants.

TREATMENT PLANNING edgewise appliances, and .014-in nickel-titanium align-

Both cephalometric prediction and paper surgery ing archwires were ligated. At 3 months of treatment,
has been done. For presurgical orthodontic treatment, .016 3 .022-in stainless steel archwires were placed
extraction of the maxillary first premolars and the max- in the maxillary arch. En-masse retraction was started,
imum retraction of the maxillary anterior segment were and full-time Class II elastics were used for 7 months.
planned, because the patient had an acute nasolabial an- At 12 months of treatment, microimplants (diameter,
gle and proclined maxillary inciors. Because the incisal 1.2 mm; length, 10 mm; Absoanchor, Daegu, Korea)
tip of the maxillary incisors was positioned high in rela- were placed in the palatal alveolar bone between the
tion to the reposed upper lip, extrusion of the maxillary roots of the maxillary first and second molars on both
incisors was planned during distal retraction and lingual sides (Fig 3). To prevent linguoversion of the maxillary
tipping of the maxillary incisors. Labioversion of the posterior teeth during application of the intrusive force
mandibular incisors provides a better chin-lower lip from the palatal side, a transpalatal bar was placed.
line. An intrusive force of 100 g was applied immediately
To change the maxillary occlusal plane in the clock- from the microimplants to the lingual cleat on the pala-
wise direction, intrusion of the maxillary posterior teeth tal surface of the maxillary second molars on both sides.
was planned. Intrusion of the posterior teeth seemed After the extraction spaces were closed completely, the
more rational than extrusion of the anterior teeth, be- arch forms of both arches were coordinated.
cause the vertical position of the maxillary incisors After 18 months of treatment, the patient transferred
could allow only 2 mm of extrusion, and extrusion of to the Department of Oral and Maxillofacial Surgery,
the anterior teeth is reportedly more prone to re- and bilateral sagittal split ramus osteotomy and mandib-
lapse.14,15 Microimplants can be used for anchorage to ular repositioning were performed according to the
intrude the maxillary posterior teeth. The decision on Epker method. The amount of mandibular setback was
the amount of intrusion was made on the basis of the 13 mm on both sides.
paper surgery. Bilateral sagittal split ramus osteotomy After 6 weeks of intermaxillary fixation, orthodontic
was planned. treatment was resumed. Final arch coordination and
minimal occlusal equilibration were performed. The or-
thodontic braces were debonded, and all microimplants
TREATMENT PROGRESS were removed by unscrewing without anesthesia 7
The maxillary and mandibular third molars and both months after orthognthic surgery. The total length of
maxillary first premolars were extracted. All teeth in treatment was 25 months. After treatment, lingual re-
both arches were then fitted with fixed preadjusted tainers were bonded from first premolar to first premolar
American Journal of Orthodontics and Dentofacial Orthopedics Park, Kim, and Kwon 635
Volume 138, Number 5

Fig 4. Posttreatment records.

in the mandibular arch, and an additional clear retainer relative to the nasion-perpendicular line changed from
was delivered. 80 to 100 , –5 to 2 , and 16.8 to 2.6 mm, respectively
(Fig 6, Table). Because of the intrusion of the maxillary
TREATMENT RESULTS posterior teeth, the occlusal plane and the mandibular
After treatment, good facial balance and occlusal re- plane to the FH plane showed clockwise rotation; ac-
lationship were obtained (Fig 4). Class I canine and cordingly, the occlusal plane angle increased from
Class II molar relationships, with normal overbite and –2.8 to 3.5 , and the FMA increased from 19 to
overjet, and coincident dental midlines were obtained 25.5 without changing the vertical dimension.
(Fig 5). An appropriate interincisal relationship was The 15-month retention records showed good reten-
achieved by distal uprighting of the maxillary anterior tion without obvious relapse (Fig 7). The occlusion was
teeth and labioverion of the mandibular anterior teeth. stable, and a good facial profile was also retained.
No marked root resorption was seen in the panoramic
radiograph.
The nasolabial angle had become more obtuse be- DISCUSSION
cause of the retraction and distal uprighting of the max- In the treatment of adults with skeletal Class III
illary anterior teeth. The prognathic chin moved maloccclusion, orthognathic surgery is one of the best
backward properly. The pretreatment and posttreatment treatment options. The position of the mandible is
cephalometric measurements showed that the nasola- determined by the 3-dimensional position of the maxilla
bial angle, the ANB angle, and the position of pogonion in Class III orthognathic surgery.
636 Park, Kim, and Kwon American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Fig 5. Posttreatment digital dental casts.

Fig 6. Cephalometric superimpositions between pretreatment and posttreatment.

American Journal of Orthodontics and Dentofacial Orthopedics Park, Kim, and Kwon 637
Volume 138, Number 5

Fig 7. Retention records at 15 months.

A 1-jaw mandibular surgery is a more predictable maintaining the total posterior vertical dimension.19,20
procedure. There was no statistical difference in the po- However, a surgical procedure involving the maxilla is
sition of the skeletal hard tissues between the prediction complicated and variable. Jacobson and Sarver21 found
and the actual results.16 However, in 1-jaw surgery, the that the positioning of the maxillary molar in the vertical
mandible tends to set back with counterclockwise rota- dimension by surgery tended to be inferior to the
tion in patients who have a flat occlusal plane. This prediction and led to the greatest statistical difference
limits the amount of backward movement of the chin. between the predicted and actual positions. Semaan and
It has been reported that patients with a flat occlusal Goonewardene22 also reported a statistically significant
plane had insufficient profile changes after 1-jaw differences between the predicted and actual postsurgical
surgery.17 Also, postsurgical stability after counterclock- maxillary molar vertical positions. Approximately
wise rotation of the mandible is poor because of the two-thirds (66%) of the subjects had their maxilla
increase in posterior facial height and the associated positioned within 2 mm of the prediction, and about
increase in vertical length of the pterygo-masseteric a quarter (26%) of the maxillae were placed within
musculature.18 1 mm of the predicted outcome. The results suggest
Two-jaw surgery is normally performed in patients that maxillary surgery has great variability. It is difficult
who need the position of the maxillary teeth or the to achieve the treatment goals determined by prediction
cant of the occlusal plane changed. The 2-jaw surgery in the position of the maxilla by orthognathic surgery.
with clockwise rotation of the maxillary occlusal plane Microimplants can provide stationary anchorage
could be considered to achieve the maximum esthetic for tooth movement in all directions.4,8,10 The teeth
results. Also, the impaction of the posterior segment can be moved orthodontically and precisely to their
in Class III orthognathic surgery increases stability by predicted goals with microimplants. A microimplant
638 Park, Kim, and Kwon American Journal of Orthodontics and Dentofacial Orthopedics
November 2010

Fig 8. Path changes of mandibular setback surgery and its effect on the profile (blue, before surgery;
red, after treatment): A, path of the mandibular setback without intrusion of the posterior teeth;
B, path of the mandibular setback with intrusion of the posterior teeth. MI, Microimplant.

Fig 9. Superimpositions between treatment results and surgical treatment objectives prediction.

can move teeth in 3 dimensions including bodily maxillary impaction. The patient had a flat occlusal
retraction of maxillary anterior teeth,3,4,7,11,12 intrusion plane; the angle of the maxillary occlusal plane to the
of teeth,8,12,23 and protraction of mandibular molars10 FH plane was –2.8 . The maxillary occlusal plane was
for decompensation of the mandibular incisors. Changes rotated backward and upward by the 2-mm intrusion
in the cant of the maxillary occlusal plane can also be of the maxillary posterior teeth. As a result, the chin
obtained by intrusion of the maxillary posterior teeth. moved distally by 4 more mm compared with the surgi-
The clockwise rotation of the maxillary occlusal plane cal treatment objectives, which estimated the results of
can cause clockwise rotational setback of the mandible, 1-jaw mandibular surgery without changing the maxil-
and this brings about more distal movement of the chin lary occlusal plane (Fig 9). Small vertical changes
(Fig 8). Intrusion of the posterior teeth with microim- in the posterior teeth could produce profound changes
plants produced similar effects on the profile as surgical in the anterior area. This effect is obviously seen in
American Journal of Orthodontics and Dentofacial Orthopedics Park, Kim, and Kwon 639
Volume 138, Number 5

the cephalometric superimpositions between after- during the retraction of the maxillary incisors with mi-
treatment results and surgical treatment objectives croimplants changes the occlusal plane in a clockwise
prediction (Fig 9). The facial harmony was improved direction. This increases the amount of surgical mandib-
dramatically. The ANB angle increased from –5 to ular setback or distal movement of the chin, and pro-
2 . The FMA angle increased from 19 to 22.5 without duces similar effects on a profile as does 2-jaw
increases of anterior and posterior vertical height. surgery that includes maxillary posterior impaction.
There are many successful case reports of intrusion
of posterior teeth by using microimplants.8,12,23,24
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