CASE REPORT

Chin remodeling in a patient with

bimaxillary protrusion and open
bite by using mini-implants for
temporary anchorage
Chunmiao Jiang,a,b Yinghong Liu,c Qian Cheng,c Wei He,d Shanbao Fang,c Tingting Lan,c and Jun Wangc
Chengdu and Mianyang, Sichuan, and Qingdao, Shandong, China

Patients with bimaxillary protrusion may have an unattractive profile with a retruded chin contour. Correction of
the severely protrusive anterior alveolar bone and teeth combined with a moderate open bite without orthog-
nathic surgery can be challenging. This case report describes the orthodontic treatment of a woman with severe
bimaxillary protrusion and a moderate open bite. Excellent chin morphology and facial appearance were ob-
tained with the extraction of 4 first premolars and 4 third molars, and total distalization of both arches with 4
mini-implants, one in each quadrant between the second premolar and the first molar. The total treatment
time was 30 months. (Am J Orthod Dentofacial Orthop 2018;153:436-44)

T
he chin plays an important role in the overall har- anterior teeth. However, 1 premolar space is usually not
mony of the facial profile. It has been generally enough to alleviate the dentoalveolar protrusion, especially
suggested that when evaluating facial esthetics, when patients have an open bite as well. Some authors
the public mostly considers the lower third of the face have reported that extracting second molars or both pre-
rather than the other facial structures.1,2 Patients with molars in the same quadrant could generate enough space
bimaxillary dentoavelolar protrusion usually have a to retract the anterior teeth and create an acceptable facial
retrusive chin contour, occasionally combined with a profile.5-8 However, these tooth extraction patterns might
mild to severe open bite.3,4 These patients are often lead to loss of molar and premolar function and cause
treated with a combination of orthodontics and disturbance of the occlusion.
orthognathic surgery to improve their facial esthetics. Currently, implants are widely used to help retract the
A common treatment approach for bimaxillary protru- anterior teeth, and some authors have used them to dis-
sion patients is to extract 4 premolars and then retract the talize the whole arch.9,10 In addition, mechanical
analysis related to full-arch distalization with a temporary
a
anchorage device has been elucidated.9,11 However, when
State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral
Diseases, Department of Orthodontics, West China Hospital of Stomatology,
using skeletal anchorage to treat bimaxillary protrusion,
Sichuan University, Chengdu, Sichuan, China. some patients obtain good chin morphology and a
b
Department of Orthodontics, the Affiliated Hospital of Qingdao University, good lateral profile, but others do not; this is always
Qingdao, Shandong, China.
c
State Key Laboratory of Oral Diseases, National Clinical Research Center for Oral
perplexing to orthodontists.
Diseases, Department of Orthodontics, West China Hospital of Stomatology, Here we report on a patient with severe bimaxillary
Sichuan University, Chengdu, Sichuan, China.
d
protrusion and moderate open bite treated by extraction
Department of Orthodontics, Mianyang Central Hospital, Mianyang, Sichuan,
China.
of 4 first premolars and 4 third molars, and retraction of
All authors have completed and submitted the ICMJE Form for Disclosure of the anterior teeth and the full arches distally with mini-
Potential Conflicts of Interest, and none were reported. implants. See Supplemental Materials for a short video
Address correspondence to: Jun Wang, State Key Laboratory of Oral Diseases,
National Clinical Research Center for Oral Diseases, Department of Orthodontics,
presentation about this study.
West China Hospital of Stomatology, Sichuan University, No.14, 3rd section,
People's South Road, Chengdu, Sichuan, 610041, China; e-mail, wangjunv@
scu.edu.cn.
DIAGNOSIS
Submitted, July 2016; revised and accepted, November 2016. A woman, aged 24 years 3 months, was referred for
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved. an orthodontic consultation in Department of Ortho-
https://doi.org/10.1016/j.ajodo.2016.12.030 dontics, West China Hospital of Stomatology, Sichuan
436
Jiang et al
University, Chengdu, China. Her chief complaints were
self-consciousness about her lip protrusion and lack of
contact of her anterior teeth. Her lips were incompetent
because of the severe proclination of her anterior teeth
and open bite at rest.
The clinical examination showed a symmetric face,
incompetent lips, acute nasolabial angle, and convex
lateral profile without a chin contour (Fig 1). She had a
5-mm overjet and a 4-mm open bite, with a Class I molar
relationship on both sides. The maxillary and mandibular
anterior teeth were significantly proclined, but there was
almost no crowding in either arch (Fig 2). She had caries
on the maxillary second molars and silver amalgam fill-
ings in her 4 first molars. The 4 third molars had erupted,
and the mandibular right third molar was mesially and
horizontally impacted. A panoramic radiograph showed
that the mandibular right first molar had received root
canal treatment (Fig 3, A).
The lateral cephalometric analysis showed a skeletal
Class I jaw relationship (ANB, 4.4 ) with a hyperdivergent
growth pattern (SN-MP, 39.7 ). The maxillary and
mandibular anterior teeth were severely proclined
(U1-SN, 64.2 ; L1-MP, 106.9 ; U1-L1, 95.3 ). Her lips
were protrusive, with upper lip to E-line at 2.5 mm
and lower lip to E-line at 6.1 mm (Table; Fig 3, B and C).
Based on the measurements and analysis above, the
patient was diagnosed with dental and skeletal Class I bi-
maxillary protrusion and anterior open bite.
TREATMENT OBJECTIVES
The treatment objectives were to improve the lateral
profile, obtain ideal inclination of the anterior teeth, cor-
rect the anterior open bite to normal overbite and overjet,
and maintain the Class I molar and canine relationships.
TREATMENT ALTERNATIVES
Three alternative treatment plans were identified. The
first was to perform an anterior segmental osteotomy
combined with genioplasty. The second was to extract
the mandibular right first molar, which had a large silver
amalgam filling, and the first premolars in the other 3
quadrants, and fully retract the anterior teeth and the
whole maxillary and mandibular dentitions by using
temporary anchorage devices. The third treatment option
was to extract the 4 first premolars and then to retract the
anterior teeth and dentition distally with mini-implants.
In addition, the patient was informed that the mandib-
ular right first molar had a risk of loosening in the future.
The patient refused the surgical treatment plan and
did not want her mandibular right first molar extracted.
She accepted the risk that the molar might loosen in the
future. Therefore, the third treatment plan was selected.
American Journal of Orthodontics and Dentofacial Orthopedics
437
TREATMENT PROGRESS
Before orthodontic treatment, the patient saw a peri-
odontist for cleaning and treatment. After that, she went
to the Department of Oral and Maxillofacial Surgery,
West China Hospital of Stomatology, Sichuan University
for extraction of her 4 first premolars. A preadjusted
appliance with 0.022-in slots (Damon Q; Ormco, Berlin,
Germany) was bonded from the anterior teeth to the sec-
ond premolars for alignment and leveling with copper-
nickel-titanium archwires. To protect the mandibular
right first molar, first molar bands were placed on the
first molars. After 7 months, the maxillary and mandib-
ular arches were leveled, and 0.019 3 0.025-in stainless
steel arches were placed. Four mini-implants
(1.6 3 9 mm; Medicon, Tuttlingen, Germany) were im-
planted, one in each arch between the second premolar
and the first molar (Fig 4, A). The anterior teeth were re-
tracted en masse using nickel-titanium closed-coil
springs and power chain retracting from the mini-
implants to the short hooks on the wire between the
lateral incisor and the canine. Rocking chairs were
used in both aches to control the labiolingual inclination
of the anterior teeth, and the torque on the wires of the
posterior teeth was eliminated.
In month 19 of treatment, the mandibular premolar
extraction space and anterior open bite were closed;
the implants in the mandible were loose, and about
3 mm of extraction space was observed in the maxillary
arch. The patient still had protrusive lips, and the chin
contour was not obvious. At the same time, the maxillary
anterior teeth were retained by the mandibular anterior
teeth, so the patient was sent to an oral surgeon to
extract her 4 third molars to fully retract the anterior
teeth and the entire dentition. Four second molars
were bonded with brackets and the new mini-implants
(1.4 3 8 mm; Ormco) were placed between the mandib-
ular first molars and second molars to distalize the whole
dentition (Fig 4, B). Meanwhile, the short hooks were re-
placed with long hooks to better control the inclination
of the anterior teeth.
Six months later, the extraction spaces were closed in
both arches, and the maxillary and mandibular
second molar region formed a “Tweed” occlusion.
Brackets and first molar bands were removed to allow
the posterior molar occlusion to adjust by itself. In
month 28 of treatment, a small bend was added to the
wire for better interdigitation of the maxillary and
mandibular premolars and molars.
The total treatment time was 30 months. The
mandibular dentition distalization took 6 months. The
mandibular implants were loose at 1 time during treat-
ment and were reimplanted 1 month later. After we
March 2018  Vol 153  Issue 3
438
Fig 1. Pretreatment facial and intraoral photographs.
removed all appliances, removable soft retainers were
used in both arches, and an additional Hawley retainer
was delivered at the same time for use at night.
TREATMENT RESULTS
The posttreatment photographs showed an ideal chin
contour and an improved profile. Lip protrusion
decreased, with the upper lip to E-line at 0.7 mm, and
the lower lip to E-line at 1.3 mm. Chin thickness
increased after treatment, with 1.48 mm in soft tissue po-
gonion and 2.79 mm in soft tissue menton. The retrac-
tion and proper incisor position allowed for upper and
lower lip curl and a balanced lip position (Figs 5 and 6).
The panoramic radiograph showed proper space
closure and good root paralleling with no significant
sign of bone or root resorption (Fig 7, A). The lateral ceph-
alogram and tracing (Fig 7, B and C) showed an
March 2018  Vol 153  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al
orthognathic profile with an ideal maxillary and mandib-
ular incisor relationship. The superimpositions showed
the amounts of retraction and uprighting of the maxillary
and mandibular incisors that contributed to the ideal pro-
file (Fig 8). The anterior open bite was closed, and Class I
canine and molar relationships were maintained with a
canine-protected occlusion (Fig 6). The maxillary and
mandibular incisors were retracted and uprighted
(U1-SN, 64.2 to 80.5 ; L1-MP, 106.9 to 89.4 ;
U1-L1, 95.3 to 130.8 ). The mandibular plane angle
was maintained after orthodontic treatment (SN-MP,
39.7 to 39.6 ).
DISCUSSION
In patients with bimaxillary protrusion, chin
morphology, lip protrusion, and incisor position are
key objective measurements correlated with facial
Jiang et al 439

Fig 2. Pretreatment dental models.

Fig 3. Pretreatment radiographs: A, panoramic radiograph; B, cephalometric radiograph; C, cephalo-

metric tracing.

esthetics.12 Chin morphology is a key point in facial es- patient's chin was repressive; after treatment, the
thetics, and the increase of the mentolabial sulcus depth changes of the protrusive upper and lower lips achieved
improved the profile. Before orthodontic treatment, the facial balance and harmony with ideal chin morphology.

American Journal of Orthodontics and Dentofacial Orthopedics March 2018  Vol 153  Issue 3
440 Jiang et al

Table. Cephalometric measurements

Measurement Normal Pretreatment Posttreatment Difference
SNA ( ) 81.69 6 4.7 83.7 82.2 1.5
SNB ( ) 78.94 6 3.4 79.3 78.9 0.4
ANB ( ) 2.75 6 1.5 4.4 3.3 1.1
SN-MP ( ) 32.85 6 6.0 39.7 39.6 0.1
y-axis ( ) 60.3 6 3.4 69.5 69.8 0.3
S-Go/N-Me (%) 65.85 6 4.0 60.6 61.3 0.7
ANS-Me/N-Me (%) 53.32 6 3.0 56.5 56.1 0.4
U1-L1 ( ) 123.22 6 6.0 95.3 130.8 35.5
U1-SN ( ) 74.94 6 5.5 64.2 80.5 16.3
Ul-NA (mm) 5.56 6 2.7 9.7 3.3 6.4
Ul-NA ( ) 23.26 6 5.7 32.1 17.5 14.6
Ll-NB (mm) 5.76 6 1.8 12 5.9 6.1
Ll-NB ( ) 27.38 6 6 42.2 28.5 13.7
L1-MP ( ) 95 6 7 106.9 89.4 17.5
U6-PP (mm) 22 6 2 21 20 0.1
L6-MP (mm) 35 6 3 30 29 0.3
UL-EP (mm) 0.46 6 2 2.5 0.7 3.2
LL-EP (mm) 1.31 6 2 6.1 1.3 4.8
Pog-Pog’ (mm) 9.96 6 2.06 4.19 5.67 1.48
Gn-Gn’ (mm) 6.01 6 2.23 2.18 4.36 2.18
Me-Me’ (mm) 6.52 6 2.14 2.53 5.32 2.79

Fig 4. Treatment progress: A, 4 mini-implants were implanted between the second premolar and the
first molar; B, extraction of 4 third molars to fully retract the anterior teeth and the entire dentition.

Analyzing the correlating measurements of hard and
soft tissues, we found that the following factors contrib-
uted to the improvement of her chin morphology during
the orthodontic treatment.
The most important factor was that the maxillary and
mandibular incisors were relocated. The more the ante-
rior incisors were retracted, the more the lips were re-
tracted, leading to forward movement of the chin,
relatively. According to the theory of six elements,13
chin prominence is optimal when pogonion matches
the prominence of the facial axis (Element I). In this pa-
tient, the total maxillary incisor retraction was 6.4 mm
including tipping, and bodily and intrusion movement,
and the mandibular incisor retraction was 6.1 mm with
only tipping movement. Consequently, there was bone
remodeling in skeletal A-point but not in B-point.
Although skeletal B-point and pogonion did not have
bone remodeling (SNB, 79.3 to 78.9 ; Pg-NP,
1.7 mm to 1.7 mm), ideal chin morphology was the
result. So the position of the mandibular incisors might

March 2018  Vol 153  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al 441

Fig 5. Posttreatment facial intraoral photographs.

Fig 6. Posttreatment dental models.

American Journal of Orthodontics and Dentofacial Orthopedics March 2018  Vol 153  Issue 3
442
Fig 7. Posttreatment radiographs. A, panoramic radiograph; B, cephalometric radiograph; C, cepha-
lometric tracing.
be more important than skeletal B-point and pogonion
when they are normal in chin morphology. In this pa-
tient, the position and inclination of her mandibular
incisor were retracted significantly after treatment, fol-
lowed by retraction of the lower lips, leading to improve-
ment of the chin morphology. This was also observed in
other reports.14,15 In view of the chin morphology
change of this patient, we postulated that, if the incisal
edges of the mandibular incisors were posterior to the
skeletal pogonion after orthodontic treatment, the
patient would have more chance for a good chin
contour. Another factor was the thickness and
looseness of the lips. Macari and Hanna16 reported that
soft tissue chin thickness was less in adult patients with
a vertical hyperdivergent pattern compared with adults
with a clinically normal and hypodivergent patterns.
The thickness and looseness of the soft tissue around
the mouth, such as upper and lower lips, and muscles,
influenced the accumulation of these tissues after retrac-
tion of the anterior teeth, and consequently the projec-
tion of chin. This patient's soft tissue tension around
the mouth was relatively low; therefore, after treatment,
the soft tissues can curve to form a good chin contour.
In addition to the factors above, it was essential
to control the vertical dimension especially for this
March 2018  Vol 153  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al
hyperdivergent patient. Before treatment, her SN-MP
angle was 39.7 , suggesting that she had a vertical growth
pattern. For a hyperdivergent patient, the molars can be
intruded with temporary anchorage devices; this is a
benefit for facial esthetics.17,18 In addition, some
authors have reported that mandibular plane inclination
and rotation would influence chin morphology, and
they used implants or extraoral devices to rotate the
mandible counterclockwise and obtain good chin
morphology and profile improvement.19,20 After
treatment, this angle in our patient was not changed
(SN-MP, 39.6 ), indicating that chin morphology
change was not due to the counterclockwise rotation of
the mandible. Aki et al21 reported that a hyperdivergent
mandible was associated with small height, small depth,
large ratio, and small angle of the chin, indicating that
the vertical skeletal pattern was associated with chin
morphology. The superimposition of the cephalograms
showed almost no vertical movement of the maxillary
and mandibular first molars, indicating that anterior
open bite correction was attributed to retraction of the
mandibular incisors; this can be called the pendulum
effect.
Recently, implants have been widely used by ortho-
dontists for whole dentition distalization,9,11 tooth
Jiang et al
Fig 8. Cephalometric superimpositions: A, overall superimposition; B, maxillary superimposition; C,
mandibular superimposition. Black, pretreatment; red, posttreatment.
intrusion,22,23 anterior tooth retraction, and molar
mesial movement.24 Some orthodontists analyzed the
movement mechanics of teeth retracted by implants.
Sung et al9 used a standard 3-dimensional finite
element model to analyze stress distribution and
displacement patterns of the entire maxillary arch
with regard to distalizing force vectors applied from
interdental miniscrews. They found that when force
was applied to the lower level hooks, initial displace-
ment of the anterior segment led to lingual inclination
and downward displacement of the incisal edges, as
well as intrusion of the posterior segment, including
the premolars and molars; this resulted in steepening
of the occlusal plane. In contrast, when force was
applied to higher level hooks, lingual root movement
and labial crown movement of the anterior teeth and
extrusion of the posterior segment occurred, resulting
in flattening of the occlusal plane. The authors
concluded that rotation of the occlusal plane depended
on the relationship between the line of force and the
possible center of resistance of the entire arch. Other re-
searchers used the same finite element model to deter-
mine the resistance of the maxillary dentition and
found that the center of resistance of the full maxillary
dentition was 11.0 mm apical to and 26.5 mm posterior
to the incisal edge of the maxillary central incisor.25 We
used a long hook (6 mm) during the retraction, which
might be much closer to the resistance of the entire
maxillary dentition and the anterior teeth than that of
American Journal of Orthodontics and Dentofacial Orthopedics
443
a short hook, so the maxillary incisors were retracted
and intruded; this can be seen in the superimposition
of cephalograms before and after treatment. The finite
element model analysis showed that bodily movement
of the anterior teeth was likely to occur when force
was applied to 4-mm or 6-mm retraction hooks; this
is consistent with the anterior tooth movement of our
patient. The mandibular occlusal plane had counter-
clockwise rotation at the end of the orthodontic treat-
ment, because the force lines from the implants to the
hooks were above the center resistance of all mandib-
ular anterior teeth, leading to their lingual inclination
movement.
CONCLUSIONS
Good chin morphology can be achieved by premolar
extraction and entire dentition distalization to avoid
surgery in patients with severe bimaxillary protrusion
and moderate anterior open bite. Three factors are
attributable to a good chin contour formation: (1) relo-
cation of the anterior teeth, (2) soft tissue tension
around the mouth, and (3) inclination and rotation of
the mandibular plane.
SUPPLEMENTARY DATA
Supplementary data related to this article can be
found at http://dx.doi.org/10.1016/j.ajodo.2016.12.
030.
March 2018  Vol 153  Issue 3
444
REFERENCES
1. Koch R, Gonzales A, Witt E. Profile and soft tissue changes
during and after orthodontic treatment. Eur J Orthod 1979;
1:193-9.
2. M€ ohlhenrich SC, Heussen N, Kamal M, Peters F, Fritz U, Holzle F,
et al. Influence of setback and advancement osseous genioplasty
on facial outcome: a computer-simulated study. J Craniomaxillo-
fac Surg 2015;43:2017-25.
3. Keating PJ. Bimaxillary protrusion in the Caucasian: a cephalo-
metric study of the morphological features. Br J Orthod 1985;
12:193-201.
4. Zhang J, Qiao M. Cephalometric analysis of the patients with bi-
maxillary protrusion in south China. Hua Xi Kou Qiang Yi Xue Za
Zhi 2001;19:32-4.
5. Staggers JA. A comparison of results of second molar and first pre-
molar extraction treatment. Am J Orthod Dentofacial Orthop
1990;98:430-6.
6. Iijima S, Yoshida M, Terada K. Treatment of dentoskeletal bimax-
illary protrusion: additional extraction of maxillary second molars.
Odontology 2009;97:115-9.
7. Kook YA, Park JH, Bayome H, Sa'aed NL. Correction of severe bi-
maxillary protrusion with first premolar extractions and total arch
distalization with palatal anchorage plates. Am J Orthod Dentofa-
cial Orthop 2015;148:310-20.
8. Park HS, Kwon TG. Sliding mechanics with microscrew implant
anchorage. Angle Orthod 2004;74:703-10.
9. Sung EH, Kim SJ, Chun YS, Park YC, Yu HS, Lee KJ. Distalization
pattern of whole maxillary dentition according to force application
points. Korean J Orthod 2015;45:20-8.
10. Chen K, Cao Y. Class III malocclusion treated with distalization of
the mandibular dentition with miniscrew anchorage: a 2-year
follow-up. Am J Orthod Dentofacial Orthop 2015;148:1043-53.
11. Chung KR, Kim SH, Choo HR, 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;137:135-46.
12. Hayashida H, Ioi H, Nakata S, Takahashi I, Counts AL. Effects of
retraction of anterior teeth and initial soft tissue variables on lip
changes in Japanese adults. Eur J Orthod 2011;33:419-26.
13. Andrews LF, Andrews WA. The six elements of orofacial harmony.
Andrews J 2000;1:13-22.
March 2018  Vol 153  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jiang et al
14. Saxby PJ, Freer TJ. Dentoskeletal determinants of soft tissue
morphology. Angle Orthod 1985;55:147-54.
15. Arnett GW, Jelic JS, Kim J, Cummings DR, Beress A, Worley CM Jr,
et al. Soft tissue cephalometric analysis: diagnosis and treatment
planning of dentofacial deformity. Am J Orthod Dentofacial Or-
thop 1999;116:239-53.
16. Macari AT, Hanna AE. Comparisons of soft tissue chin thickness in
adult patients with various mandibular divergence patterns. Angle
Orthod 2014;84:708-14.
17. Nicolaievsky E. The use of temporary anchorage devices for molar
intrusion and treatment of anterior open bite. Blum Oral-Facial
Surgery Associates 1980:1-6.
18. Cousley RR. Molar intrusion in the management of anterior open-
bite and ‘high angle’ Class II malocclusions. J Orthod 2014;
41(Supp 1):S39-46.
19. Baek MS, Choi YJ, Yu HS, Lee KJ, Kwak J, Park YC. Long-term sta-
bility of anterior open-bite treatment by intrusion of maxillary
posterior teeth. Am J Orthod Dentofacial Orthop 2010;138:
396.e1-9: discussion, 396-8.
20. Park YC, Lee SY, Kim DH, Jee SH. Intrusion of posterior teeth using
mini-screw implants. Am J Orthod Dentofacial Orthop 2003;123:
690-4.
21. Aki T, Nanda RS, Currier G, Nanda SK. Assessment of symphysis
morphology as a predictor of the direction of mandibular growth.
Am J Orthod Dentofacial Orthop 1994;106:60-9.
22. Scheffler NR, Proffit WR, Phillips C. Outcomes and stability in pa-
tients with anterior open bite and long anterior face height treated
with temporary anchorage devices and a maxillary intrusion splint.
Am J Orthod Dentofacial Orthop 2014;146:594-602.
23. Nishimura M, Sannohe M, Nagasaka H, Igarashi K, Sugarawara J.
Nonextraction treatment with temporary skeletal anchorage de-
vices to correct a Class II Division 2 malocclusion with excessive
gingival display. Am J Orthod Dentofacial Orthop 2014;145:
85-94.
24. Chhibber A, Upadhyay M. Anchorage reinforcement with a fixed
functional appliance during protraction of the mandibular second
molars into the first molar extraction sites. Am J Orthod Dentofa-
cial Orthop 2015;148:165-73.
25. Jeong GM, Sung SJ, Lee KJ, Chun YS, Mo SS. Finite-element inves-
tigation of the center of resistance of the maxillary dentition.
Korean J Orthod 2009;39:83-94.