Infra-Zygomatic Crest and Buccal Shelf - Orthodont

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254]
Invited Submission: JIOS 50th Year Commemorative Issue
Infra-Zygomatic Crest and Buccal Shelf - Orthodontic Bone Screws:

A Leap Ahead of Micro-Implants – Clinical Perspectives
Abhisek Ghosh
Consultant Orthodontist Absolute anchorage systems have stormed the world of orthodontics over the past
Abstract
Department of Orthodontics two decades with its ability to produce skeletal anchorage, converting borderline
and Dento-Facial surgical cases into non-surgical and extraction cases into non-extraction or even
Orthopedics, Great bringing about the esthetic impact which was difficult to achieve by conventional
Lakes Dental Clinic and mechanics. Among the skeletal anchorage systems, the most popular being – mini-
Orthodontic Centre, implants or micro-screws which have an intra-radicular site of placement. Their
Kolkata, West Bengal, India
greatest advantage being the ease and minimally invasive methods of placement
and the commonest disadvantage being early loosening during the course of
treatment. A more rigid alternative was then introduced called as the SAS
-Skeletal Anchorage Systems (I-plate, Y-plate etc) with its extra-radicular site of
placement, which did overcome the high failure rates of a regular mini-implant but
then their placement required raising of flaps and extensive surgical intervention.
More recently an apt balance was achieved with the advent of the -Orthodontic
Bone Screws (OBS) which not only had an extra-radicular site of placement in
the infra-zygomatic crest of the maxilla and the buccal shelf area of the mandible,
with significantly less failure rates than regular mini-implants but also doesn’t
require extensive surgical intervention for their placement. This article is aimed
at providing an overview - to the recently introduced OBS system, their technical,
bio material and bio-mechanical differences with the commonly used mini-implant
system, the case selection criteria, advantages, disadvantages and an in-depth to
the cases treated with them.
Keywords: Biomechanics of bone screws, biomechanics of micro-implants,
Received: 14‑11‑2018
BSS, buccal shelf area, full arch distalization, infra-zygomatic crest, IZC,
Accepted: 14‑11‑2018 micro-implants, orthodontic bone screws
Introduction They have not only been able to solve the problems related
to anchorage but also microimplant‑mediated segmental
O rthodontics in its century of existence have had a
lot of landmarks in its evolution, but very few can
match the clinical impact made by micro-implants and the
distalization or full arch distalization with extra‑radicular
bone screws have been able to treat cases the non‑extraction
recently introduced infra-zygomatic crest (IZC) and buccal way or even retreat cases with anchorage loss.
shelf (BS) orthodontic bone screws. Micro‑implants Orthodontic retreatment being so common these
and extra‑radicular bone screws have brought about a days – courtesy poor mechanics, it is the need of the
renaissance to the field of orthodontics with its concept
of absolute anchorage in the past decade. It is an added Address for correspondence: Dr. Abhisek Ghosh,
armamentarium in the hands of an experienced clinician Department of Orthodontics and Dento‑Facial Orthopedics,
Great Lakes Multispeciality Dental Clinic and Orthodontic Centre,
to overcome new clinical challenges and convert 27, Janak Road (Behind Lake Mall), Kolkata ‑ 700 029,
even borderline surgical cases to nonsurgical without West Bengal, India.
compromising with the results achieved. However, the E‑mail: dr.abhisek24@gmail.com
choice of cases still remains the key to clinical success. This is an open access journal, and articles are distributed under the terms of the
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DOI: How to cite this article: Ghosh A. Infra-zygomatic crest and buccal shelf -
10.4103/jios.jios_229_18 Orthodontic bone screws: A leap ahead of micro-implants – Clinical
perspectives. J Indian Orthod Soc 2018;52:S127-41.
© 2018 Journal of Indian Orthodontic Society | Published by Wolters Kluwer ‑ Medknow S127

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Ghosh: Infra-zygomatic crest and buccal shelf - Orthodontic bone screws – Clinical perspectives
hour that the able orthodontist finds an alternative Difference in the choice of material between bone
means of rehabilitating debilitated clinical situations. screws and micro‑implants
The introduction of infra‑zygomatic and buccal shelf Almost every micro‑implant available in the market
screws can just provide that ray of hope together with is made with an alloy of – titanium, aluminum and
limiting the time required for re‑treatment. However, vanadium (Ti6Al4Va) and bone screws are also available
they need to be used judiciously. The anatomic limits, with similar compositions but the choice of material is
pure stainless steel. Bone screws are generally placed
art, biomechanical perspectives, and the side effects are
in areas of DI (>1250 HU) quality bone (IZC and BS
of prime considerations to master the technique.
areas) and therefore requires greater fracture resistance.
Stainless steel provides greater fracture resistance than
Extra Radicular Bone Screws and
Ti alloy and is therefore the preferred material of choice
Their Difference with Micro‑Implants [Table 1].[1]
Although both extra-radicular bone screws (IZC, BS) and
micro‑implants are classified under temporary anchorage Case Selection Criteria for Bone
devices – micro‑implants are placed in between the roots Screws
of teeth (mostly) – intra‑radicular, while bone screws Orthodontic bone screws can be used in almost every
are placed away from the roots in the infra‑zygomatic clinical situation that a micro‑implant is used for,
areas of the maxilla and the buccal shelf areas of the except that they cannot be placed inter‑dental purely
mandible – extra‑radicular. Both of them however are because of their larger dimension. They can be used for
used for the purpose of skeletal anchorage.[1] molar uprighting, segmental, and full arch distalization,
intrusion of single tooth to full arch, protraction and
Difference in sizes between bone screws and retraction of dentition and for any other anchorage
micro‑implants needs.
While the regular size of a micro‑implant ranges However, two most specific indications would
between 6 and 11 mm in length and 1.3–2 mm in be – full arch distalization of maxillary and
diameter depending on the clinical situation, it needs to mandibular dentition to camouflage a Class II and
be used for; bones screws are comparatively larger in a Class III malocclusion and for distalization of
size ranging from 10 to 14 mm in length and a minimum arches in re‑treatment cases of anchorage loss, which
diameter of 2 mm. Just like a micro‑implant may be are otherwise difficult to be done with a regular
available as a short or a long head one, bone screws micro‑implant or time‑consuming.[1,2]
are also available as a short or a long collar depending
on the anatomic site and the clinical situation it needs Table 1: Comparison of properties of stainless steel and
to be used for. Their head shapes may also vary just as titanium alloy
Properties Stainless steel Titanium alloy
micro-implants, the common being mushroom shaped
Elastic modulus (Gpa) 193 100
[Figure 1].[1] Yield strength (Mpa) 170‑1210 795
Tensile strength (Mpa) 480‑1300 860
Ductility (%) 12‑40 10
Figure 1: Bone screw specifications: Infra‑zygomatic crest, BSS Figure 2: Localization of the infra‑zygomatic crest of the maxilla
S128 Journal of Indian Orthodontic Society ¦ Volume 52 ¦ Special Issue ¦ December 2018
Sites for Placement of Bone Screws Both the areas have D1 (>1250 HU) quality bone.[1,2]
The preferred site for placement of bone screws in the
maxilla is the infra-zygomatic crest which lies higher and
Preferable Sizes of Orthodontic Bone
lateral to the 1st and 2nd molar region [Figure 2].[1,2] While Screws
some authors (Lin) prefer bone screws to be placed in the Orthodontic bone screws in the maxilla (IZC) are available
1st and 2nd molar region others (Liou) opine a more anterior in two sizes commonly (manufacturer specific) – 12 and
placement, closer to the MB root of the 1st molar [Figure 3]. 14 mm in length and 2 mm in diameter. When the soft
The preferred site for placement of bone screws in the tissue in the buccal vestibule is thick as in most clinical
mandible is the buccal shelf area, which lies lower and situations, the preferred choice is a 14 mm screw which
lateral to the 2nd molar region [Figures 4 and 5]. Buccal have 7 mm of head and collar area and 7 mm of cutting
shelf bone screws can also be placed in the external spiral. Orthodontic bone screws of 12 mm length are
oblique ridge of the mandible if the buccal shelf area preferred in cases of thin soft tissue at the vestibule. The
is found to be too thin or too deep, as is so commonly length of cutting spiral, head, and collar dimensions may
seen in the Indian population. vary according to the choice of manufacturer.
Bone screws in the mandible are available in two sizes
commonly (manufacturer specific) – 10 mm and 12 mm
in length and 2 mm in diameter. Buccal shelf area in the
Indian population is mostly found to be thin and deep;
therefore, the preferred choice will be a 12‑mm screw.
The head and collar sizes of both the variants (10 and
12 mm) are almost the same but may vary according to
the choice of the manufacturer.
Concepts of Placement of Bone Screws

in the Infra-Zygomatic Crest and
Buccal Shelf Area
For placement of bone screws in the IZC (1st and 2nd molar
region) – initial point of insertion is inter-dentally between
Figure 3: Sites for placement of bone screws in the infra-zygomatic crest the 1st and the 2nd molar and 2 mm above the muco-gingival
junction in the alveolar mucosa. The self‑drilling screw
is directed at 90° to the occlusal plane at this point. After
the initial notch in the bone is created after couple of turns
to the driver, the bone screw driver direction is changed
by 55°–70° toward the tooth, downward, which aid in
bypassing the roots of the teeth and directing the screw to
the infra‑zygomatic area of the maxilla. The bone screw is
screwed in till only the head of the screw is visible outside
the alveolar mucosa [Figure 6]. No pre‑drilling, raising of
flap or vertical slit in the mucosa is required for insertion of
IZC screws. Immediate loading is possible and a force of
Figure 4: Localization of the buccal shelf area of the mandible up to 300–350 g can be taken up by a single bone screw.[1,2]
Figure 5: Considerations of anatomical landmarks in the buccal shelf area of the mandible
Journal of Indian Orthodontic Society ¦ Volume 52 ¦ Special Issue ¦ December 2018 S129
For placement of bone screws in the BS area of mandible

(2nd molar region), initial point of insertion is inter-dentally
between the 1st and the 2nd molar and 2 mm below the
mucogingival junction. The self‑drilling screw is directed
at 90° to the occlusal plane at this point. After the initial
notch in the bone is created after couple of turns to the
driver, the bone screw driver direction is changed by 60°–
75° toward the tooth, upward, which aid in bypassing the
roots of the teeth and directing the screw to the buccal
shelf area of the mandible. In the mandible, however,
sometimes pre‑drilling or vertical slit in the mucosa is
necessary if the bone density is too thick, however, raising
of flap is never required. Immediate loading is possible
and a force of up to 300–350 g can be taken up by a Figure 6: Considerations in the placement of infra-zygomatic bone screws
single bone screw.[1,2] However, there are varied concepts
of bone screw placement and it is best left to the clinician
to determine which is preferable for him.
Biomechanical Perspectives and Arch

Form Considerations for Retraction/
Distalization with Bone Screws in IZC
and BS Areas and Its Difference with
Micro-implant Supported Retraction
Although distalization of full arch is possible
with regular micro‑implants;[3] however, there are Figure 7: Difference in biomechanics of retraction between bone screws
limits to distalization, as micro‑implants are placed and mini‑implants
inter‑radicular and the chances of root contact during
full arch distalization process is higher unless segmental
(two‑step – first distalization and then repositioning
of screw for retraction) is done. Extra‑radicular bone
screws are safer and provide greater stability when full
arch distalization is done. However, opinions may vary
among clinicians in this perspective.
The negative side effects of retraction with bone screws
are lesser as compared to mini‑implant retraction – like
development of posterior openbite and anterior deepbite.
Due to the very position in which bone screws are placed‑the
point of application of force is more parallel and close to
the occlusal plane which reduces the chance of occlusal
plane rotation so commonly associated with mini‑implant
supported retraction [Figure 7]. However, the height of Figure 8: Transverse considerations in biomechanics
the hook and the vector of force from the bone screw still
determines the overall control on the occlusal plane.[1,2] Biologic Limits of Distalization with
With respect to arch form considerations – bone Orthodontic Bone Screws
screw‑supported retraction has serious implications. Since In the maxillary arch – the limits of distalization follow
the force is applied from a more buccally positioned the Rickett’s criteria (age‑dependent and sagittal distance
anchorage unit the chances of rolling in of molar is higher, from the pterygoid vertical). Ideally fully erupted third
which needs to be compensated with an expanded arch molars are to be removed to create space and aid in the
form or a torque in the wire whichever is suitable for the distalization process. For un‑erupted third molars placed
clinical situation. Mini‑screws due to their inter‑radicular below the cement‑enamel junction of the 2nd molars in
placement does not have such side effects [Figure 8]. young individuals, distalization is possible without their
extraction if the criterias are full filled, extractions are excellent quality of cortical bone. Reports suggest overall
however indicated at a later date to prevent relapse. failure rates of micro‑implants to be 13.5%[5] while bones
screws to be – BSS (7.2%)[6] and IZC (7%).[7]
In the mandibular arch – the limits of distalization
is the proximity of the roots of the 2nd molar to the Case Report 1: Class II Malocclusion
lingual cortical plate (angle of Inflection) [Figure 9]. For
distalization in the mandibular arch almost invariably Treated with Infra‑Zygomatic Bone Screws
3rd molar extraction is mandatory.[4] Section 1: Pretreatment assessment
History and chief complaint
Complications and Success Rate Patient named A. S, age 14 years reported with a chief
of Bone Screws as Compared to complaint of irregularity in the upper front tooth region.
Medical history revealed no history of any food or drug
Micro‑Implants allergy. Dental history revealed that he had multiple
There are hardly any complications associated with restorations done by his dentist and he had undergone
the insertion process of bone screws except for minor a composite restoration in the upper anterior teeth to
bleeding. Breakage of tip of the screw is never a close gaps but was unsatisfied with it. The extraoral
problem if pure stainless steel good quality screws are and intraoral features are summarized in Tables 2-4.
used. The most common complication associated with Figures 10 and 11 reflect these findings. Functional
bone screws are gingival overgrowth on the screw and analysis is summarized in Table 5.
early loosening of the screw. To avoid problems related
to gingival overgrowth – oral hygiene maintenance is of Table 2: Extra‑oral analysis
utmost necessity. The incidence of gingival overgrowth Parameters Inference
is far less with screws having larger heads. In case of Facial form Mesoprosopic
early loosening of the screw– re‑placement of the screw Facial symmetry No gross facial asymmetry noted, however,
is advisable in a different site. the nose is slightly deviated to the right
Chin point Matches with respect to the facial midline
As compared to micro‑implants the stability and success Occlusal plane Canted with maxillary right half of dentition
rate of bone screws are far more superior‑purely because from the lateral incisors to the molars are at a
of their larger dimension and placement sites having higher level as compared to the left side
Facial profile Mild convex
Facial height Upper facial height/lower facial height: Normal
Lower facial height/throat depth: Normal
Lips Mild protrusive
Naso‑labial angle Obtuse
Mento‑labial sulcus Shallow
Figure 9: Limits of mandibular distalization Figure 10: Pretreatment intra‑oral photographs
Figure 11: Pretreatment extra‑oral photographs Figure 12: Pretreatment extra‑oral radiographs
Table 3: Smile analysis

Parameters Inference
Smile arc Asymmetric and nonconsonant
Incisor display Rest: 1 mm
Smile: 8 mm
Lateral tooth display 1st molar to 1st molar
Buccal corridor Wide
Gingival tissue Margins: The right and left upper lateral incisor, canine and 1st premolar margins do not match
Papilla: Present in all anterior teeth but are inflamed due to poor oral hygiene
Dentition Tooth size and proportion: Upper lateral incisors are proportionately smaller in size as compared to the central incisors
which are restored to larger size to correct a preexisting midline diastema
Tooth shape: Distorted shape of upper central incisors due to broken restorations
Inclination: Proclined upper and lower incisors
Axial inclination: Maxillary teeth inclined labially
Connector space and contact area: Improper contact area between the two maxillary central incisors due to poor and
broken restoration
Incisal embrasure Improper in the upper anterior teeth due to alignment and restoration issues
Midlines Upper dental midline in shifted to the left with respect to the facial midline by 2 mm, the lower dental midline
matches with the facial midline
Table 4: Intra‑oral analysis Table 6: Comparison of cephalometric parameters pre‑

Parameters Inference and post‑treatment
Teeth present 7,654,321/1,234,567 (unerupted 8s) Variable Pretreatment Posttreatment
7,654,321/1,234,567 (unerupted 8s) Sagittal skeletal relationships (°)
Molar relation Class II on the right side and Class I on the left side SNA 76 75
Canine relation Class II on the right side and Class I on the left side SNB 73 73
Overjet 2 mm ANB 3 2
Overbite 50% Wits appraisal 1.5 1
Maxillary arch U shaped, asymmetric with spacing of 1 mm Dental base relationships (mm/°)
Mandibular U shaped, asymmetric, with spacing of 2 mm and Upper incisor to NA 7/38 4/29
arch bilaterally rotated 2nd premolars Lower incisor to NB 7/31 4/20
Oral hygiene Poor Lower (IMPA) 105 94
Dental relationships
Inter‑incisal angle 111 132
Table 5: Functional analysis Vertical skeletal relationships
Parameters Inference Max‑mand plane angles 27 27
Swallowing Normal adult pattern SN plane‑ mand plane 29 31
Temporomandibular No occlusal interferences were noted FMA 20 22
joint with normal excursive movements Soft tissues
Lower lip to Rickett’s E plane (mm) −3 0
Radiographic analysis Upper lip to S line 2 0
• Orthopantomogram – reveals spacing in the upper Nasolabial angle (°) 103 95
and lower anterior segment with unerupted 3rd molars IMPA: Incisor to mandibular plane angle
in all four quadrants with crowding in upper anterior
teeth [Figure 12] mandibular tooth material excess. Pont’s index revealed
• Lateral cephalogram – reveals proclined upper and anterior arch expansion is by 1 mm and posterior arch
lower incisors underlying a Class II skeletal base expansion possible by 1 mm. Bolton’s analysis revealed
with mild convexity of profile [Figures 12, 13 and no overall or anterior discrepancy between the upper
Table 6]. and lower dentition [Figures 10-11].
Model analysis Diagnosis
Model analysis suggested spacing of 1 mm in the Patient named A. S, age 14 years was diagnosed
maxillary arch and 2 mm in the mandibular arch. Arch as Angle’s Class II Div I subdivision right side
perimeter analysis suggested 10 mm of maxillary tooth malocclusion underlying a Class II skeletal base with
material excess and Carey’s analysis showed 4 mm of horizontal growth pattern. Other associated problems
include spacing of 1 mm in the upper arch and 2 mm Treatment options
in the lower arch, proclined and forwardly placed upper Option 1 (extraction)
and lower incisors and upper dental midline deviation to Symmetrical space closure in the lower
the left by 2 mm. Overall dental health was poor with arch (Non‑extraction protocol) followed by asymmetrical
the presence of gingivitis and multiple restorations. Soft space closure in upper arch to correct midline shift by
tissue parameters reveals protrusive lips, mild convex extraction of the upper right first premolar. The case
facial profile and presence of lip strain. The IOTN index would then finish with Class II molar relationship on the
suggests a score of 2d [Tables 7 and 8]. right side and Class I molar relationship on the left side
with bilateral Class I canine relation, corrected midline,
ideal overjet, ideal overbite, and correction of protrusive
soft‑tissue profile.
Option 2 (nonextraction)
Segmental distalization of the upper molars in
Figure 13: Pretreatment lateral cephalometric tracing Figure 14: Treatment planning
Table 7: Problem list

Pathology/ Presence of generalized gingivitis and multiple dental restorations. Poorly done and broken composite restoration in the
others upper anterior teeth to close midline diastema
Alignment 1 mm maxillary dental spacing and 2 mm of mandibular dental spacing, with rotation in mandibular second premolars
bilaterally
Dimension Skeletal Dental Soft tissue
Anteroposterior Class II skeletal base Proclined upper and lower incisors, Class II molar Protrusive lips and convex
relationship on the right side and Class I on the left side facial profile
Transverse ‑ Upper dental midline shift to the left with respect to the Slight deviation of nose to
facial midline by 2 mm the right
Vertical Low mandibular plane angle, Increased overbite of 50% ‑
reduced lower anterior facial height
Table 8: Treatment objectives

Pathology/ Oral prophylaxis and maintenance of oral hygiene and dental restorations. Removal of broken composite restoration in
others anterior teeth and re‑establish natural space which can then be restored by orthodontic means
Alignment Space closure of the upper and lower dentition by retraction to correct proclination of the upper and lower incisors.
Correction of midline discrepancy in the upper arch by asymmetrical extraction/distalization of the upper dentition
Anteroposterior ‑ Establish ideal overjet, retraction of upper and lower Reduce protrusion
incisors for correction of proclination, correction of of upper and
Class II canine and molar relation on the right side lower lips
Transverse ‑ Correction of midline discrepancy by asymmetric ‑
retraction mechanics to match upper midline to the
facial midline
Vertical Open up the mandibular plane and increase Establish ideal overbite ‑
the lower anterior facial height as a resultant
to distalization of upper arch (wedge effect)
the right side using contemporary distalization case non‑extraction both in the upper and lower
appliances (pendulum, distal jet, etc.) and treat the case arch. This would prevent the negative side effect of
nonextraction both in the upper and lower arch. The upper anterior proclination so commonly seen with
case would then finish with Class I molar and canine contemporary methods of distalization.
relation bi‑laterally, corrected midline, ideal overjet,
ideal overbite and correction of protrusive soft‑tissue
profile.
Option 3 (nonextraction)
Segmental distalization of the upper molars
in the right side using temporary anchorage
devices (mini‑implant) re‑enforced distalization
appliances (pendulum, distal jet etc.) and treat the
Figure 16: In‑treatment orthopantomogram
Figure 15: In‑treatment intra‑oral photographs
Figure 22: Posttreatment extraoral photographs
Figure 21: Posttreatment intra‑oral photographs
Figure 23: Posttreatment extra‑oral radiographs Figure 24: Posttreatment lateral cephalometric tracing
Option 4 (nonextraction) protocol was opted out. The option 4 as the best mode of
Using infra‑zygomatic bone screws for full arch distalization considering the present clinical situation was
asymmetric distalization of the upper arch which avoids opted for with patient consent. The treatment sequence and
the need of complex distalization appliances and use of biomechanics is outlined in Table 9 and Figures 15-20.
regular sliding mechanics [Figure 14]. Retention plan
Considering that the nasolabial angle was obtuse and only Fixed lingual bonded retainer was given in the upper
mild protrusion was seen in the profile– the extraction anteriors and from the canine to canine in the lower arch.
In addition, the patient was also given upper removable
wrap around retainers extending till the second molars.
The patient was advised to wear the removable retainers
for 2 years with periodic check up every 6 months.
Complications encountered during treatment
Difficulties were encountered in transverse co‑ordination
of arches mostly related to the upper arch, which was
corrected with dental expansion from an expanded
Figure 25: Superimposition on the SN plane
Figure 26: Pretreatment extra‑oral photographs
Figure 27: Pretreatment intra‑oral photographs Figure 28: Pretreatment extra‑oral radiographs
Table 9: Section II: Treatment sequence and biomechanical plan

Maxilla Mandible
Bonding of upper arch (passive self‑ligation appliance ‑ DAMON Bonding of lower arch (passive self‑ligation appliance ‑ DAMON
3MX ‑ standard torque) and initiate leveling and alignment with 3MX ‑ standard torque) and initiate leveling and alignment with
0.014, 0.018, and 0.016×0.022 Niti wires 0.014, 0.018, and 0.016×0.022 Niti wires
Continue leveling and alignment with 0.019×0.025 Niti wire, Continue leveling and alignment with 0.019×0.025 Niti wire,
followed by placement of posted (long hooks) 0.019×0.025 SS followed by placement of posted 0.019×0.025 SS wires for
wires for asymmetrical space closure and distalization symmetrical space closure
Infra‑zygomatic orthodontic bone screw of 14 mm length placed Continue closure of the lower space with e‑chain on posted
in the right upper infra‑zygomatic region and immediate loading 0.019×0.025 SS wires and anchorage from 1st and 2nd molars
done with e‑chain delivering a force of about 250‑300 G for
asymmetrical retraction of the right buccal segment to correct the
dental midline and correct overjet
Full arch distalization was continued on the right side till Class After space closure, Class II elastic support was provided on the
I molar and canine relation was attained. The arch wire was left side ‑ to maintain the Class I canine relation. The arch wire
periodically checked for transverse co‑ordination of arches was periodically checked for transverse co‑ordination of arches
Postspace closure and distalization, the arch was consolidated Postdistalization and space closure ‑ consolidation of arch was
with continuous ligature wire and 0.012 Niti wire was placed to done and the same 0.019×0.025 SS wire was kept for extended
aid in the settling process period to aid in ideal root parallelism
archwire (0.019 × 0.025 SS) and posterior negative root of any food or drug allergy. Dental history revealed that
torque added to the wire to prevent palatal cusp hang. she had visited a dentist in the past for removal of her
deciduous teeth and restorations in her permanent teeth.
Results achieved
The extraoral and intraoral features are summarized in
The case was finished with Class I incisor relationship
Tables 10-12 and reflected in Figures 26 and 27. Table 13
with normal overjet and overbite of 2 mm. The upper summarizes the functional analysis.
and lower dental midlines matched at the end of the
treatment. The right and the left buccal segment finished Radiographic analysis
with a Class I molar and canine relationship. All • Orthopantomogram it reveals spacing in the upper
displacements were corrected by the end of the treatment. and lower anterior segment with congenitally missing
No occlusal wear facets were noted with mutually all four third molars and mesial migration of the
protected occlusion and canine guided excursive lower right buccal segment [Figure 28]
movements established. A consonant smile arc was • Lateral cephalogram reveals proclined upper and
achieved and smile esthetics was significantly improved lower incisors underlying a Class III skeletal base
along with a straight facial profile [Figures 21 and 22]. with mild concavity of profile [Figures 28, 29 and
Table 14].
Lateral cephalogram reveals almost normal
inclinations of maxillary and mandibular incisors Model analysis
and Class I molar and canine relation with a Model analysis suggested total spacing of 3.5 mm in the
straight facial profile [Figures 23‑25 and Table 6]. maxillary arch and 1 mm in the mandibular arch. Arch
Orthopantomography (OPG) reveals good root divergence perimeter analysis suggested 7 mm of maxillary tooth
of the maxillary and mandibular dentition which would material excess and Carey’s analysis showed 4 mm of
attribute to the stability of the treatment results achieved mandibular tooth material excess. Pont’s index revealed
and no signs of root resorption [Figure 23]. anterior arch expansion possible by 2 mm and posterior arch
expansion possible by 1 mm. Bolton’s analysis revealed
Critical appraisal 1 mm of mandibular anterior tooth material excess and no
From an orthodontic point of view, the results were overall discrepancy between the upper and lower dentition.
close to ideal but posttreatment relapse needs to be
Diagnosis
closely monitored as the patient has not passed his phase
Patient P. S, age 22 years was diagnosed as Angle’s
of growth. The over‑all functional perspective also needs
Class III malocclusion underlying a Class III skeletal
to be taken care along with long‑term follow‑up and
base with horizontal growth pattern. Other associated
general dental health.
problems include spacing of 3.5 mm in the upper arch
Third molar extraction was advised in the upper right and 1 mm in the lower arch, proclined, and forwardly
quadrant to reduce the chances of relapse. Distalization placed upper and lower incisors and upper and lower
was possible in this case as the position of the third molars dental midline deviation to the left by 1 mm and 4 mm,
were below the level of cementoenamel junction of the respectively. Overall dental health was average with
2nd molars. In fully erupted third molars, it is advisable presence of dental caries. Soft‑tissue parameters reveal
to remove them before initiating the distalization process. protrusive lips and an orthogonal facial profile and
presence of lip strain. The IOTN index suggests a score
The root uprighting in the maxillary anterior segment was
of 2b [Tables 15 and 16].
not ideal but may not affect the overall future outcome.
The case selection, the biomechanics and appreciating the
Table 10: Extra‑oral analysis [Figure 26]
anatomic limitations would still remain as some of the Parameters Inference
important perspectives for achieving the final objective. Facial form Mesoprosopic
Facial symmetry No gross facial asymmetry noted
Case Report 2: Class III Malocclusion Chin point Slightly deviated towards the left with respect
Treated with Buccal Shelf Bone to the facial midline
Occlusal plane Normal
Screws Facial profile Orthogonal (straight)
Section 1: Pretreatment assessment Facial height Upper facial height/lower facial height: Normal
History and chief complaint Lower facial height/throat depth: Normal
Patient P. S, age 22 years, reported with a chief complaint Lips Mild protrusive
of spacing in the upper and lower front tooth region and Nasolabial angle Acute
poor smile esthetics. Medical history revealed no history Mento‑labial sulcus Shallow
Table 11: Smile analysis

Smile arc Consonant
Incisor display Rest: 1 mm
Smile: 9 mm
Lateral tooth display 2nd premolar to 2nd premolar
Buccal corridor Normal
Gingival tissue Margins: The right and left upper lateral incisor margins don’t match
Papilla: Present in all anterior teeth except in between the central incisors due to presence of midline diastema and
high frenal attachment
Dentition Tooth size and proportion: Upper lateral incisors are proportionately smaller in size as compared to the central incisors
Tooth shape: Sharp incisal tip on maxillary canines
Inclination: Proclined upper and lower incisors
Axial inclination: Maxillary teeth inclined labially
Connector space and contact area: No contact between the two maxillary central incisors due to the presence of
midline diastema and high frenal attachment
Incisal embrasure Decreased between maxillary lateral incisors and canine due to morphology of the lateral incisors
Midlines Upper and lower dental midline are shifted to the left by 1 mm and 4 mm, respectively, with respect to the facial
midline
Table 12: Intra‑oral analysis

Teeth present 7,654,321/1,234,567 (congenitally missing 8s)
7,654,321/1,234,567 (congenitally missing 8s)
Molar relation Class III right side and ¼ unit behind Class I
(super) on the left side
Canine relation Class III right side and Class I on the left side
Overjet 0 mm (edge to edge bite)
Overbite 0 mm (no overbite)
Maxillary arch U shaped with spacing of 3.5 mm
Mandibular U shaped with spacing of 1 mm (distal to right
arch canine), bilaterally rotated 2nd premolars and
mild imbrication in the lower anteriors
Figure 29: Pretreatment lateral cephalometric tracing
Oral hygiene Average
Option 2
Table 13: Functional analysis Symmetrical space closure in the upper
Parameters Inference arch (Non‑extraction protocol) followed by asymmetrical
Swallowing Normal adult pattern space closure in lower arch to correct midline shift by
Temporomandibular Occlusal interference in lateral excursive distalization of the lower right buccal segment (absence
joint movements on the right side (canine region) of third molars and available space distal to the
2nd molars).
Treatment options
The case would then finish with Class I molar and
Option 1 canine relationship bilaterally, corrected midline, ideal
Symmetrical space closure in the upper overjet, ideal overbite, and correction of protrusive
arch (Non‑extraction protocol) followed by asymmetrical soft‑tissue profile [Figure 30].
space closure in lower arch to correct midline shift by
extraction of the lower right first premolar. The case The second option was opted for with patient
would then finish with Class III molar relationship on consent. Table 17 summarizes the treatment sequence
and biomechanics.
the right side and Class I molar relationship on the left
side with bilateral Class I canine relation, corrected Retention plan
midline, ideal overjet, ideal overbite, and correction of Fixed lingual bonded retainer was given in the
protrusive soft‑tissue profile. upper anteriors and from the canine to canine in the
Table 14: Comparison of cephalometric parameters lower arch. In addition, the patient was also given
pre‑ and post‑treatment upper and lower removable wrap around retainers
Variable Pretreatment Posttreatment extending till the second molars in both the arches.
Sagittal skeletal relationships (°)
SNA 87 87
SNB 89 87
ANB −2 0
Wits appraisal −6.5 −5
Dental base relationships (mm/°)
Upper incisor to NA 7/40 6/33
Lower incisor to NB 6/33 4/26
Lower (IMPA) 95 89
Dental relationships Figure 30: Treatment planning
Inter‑incisal angle 109 123
Vertical skeletal relationships
Max‑mand plane angles 26 26
SN plane‑mand plane 28 30
FMA 20 21
Soft tissues
Lower lip to Rickett’s E 2 −1
plane (mm)
Upper lip to S line 0 −1
Nasolabial angle (°) 82 81
IMPA: Incisor to mandibular plane angle Figure 31: In‑treatment intra‑oral photographs
Table 15: Problem list

Pathology/ Normal gingival biotype on the labial of mandibular incisors. Sharp incisal tip of maxillary canines. Altered shape of
others maxillary lateral incisors. Dental caries in buccal pits of mandibular molars
Alignment 3.5 mm maxillary dental spacing and 1 mm of mandibular dental spacing, with severe rotation in mandibular second
premolars bilaterally
Dimension Skeletal Dental Soft Tissue
Anteroposterior Class III skeletal base Edge to edge bite (reduced overjet), proclined upper Protrusive lips
and lower incisors, Class III molar relationship on
the right side and Class I on the left side
Transverse Chin point deviated to the left on Crossbite tendency in relation to maxillary left Chin point deviated to
maximum intercuspation canine and mandibular left canine, upper and lower the left on maximum
dental midline shift to the left intercuspation
Vertical Low mandibular plane angle, Edge to edge bite (reduced overbite) ‑
reduced lower anterior facial height
Table 16: Treatment objectives

Pathology/ Restoration of buccal pits of mandibular molars, re‑shape maxillary canine and lateral incisor morphology if required
others to establish ideal contact areas, maintain periodontal heath of lower incisors during space closure/distalization
Alignment Space closure of upper and lower dentition by retraction to correct proclination of upper and lower incisors. Correction
of midline discrepancy in the lower by asymmetrical extraction/distalization of the lower dentition
Anteroposterior Establish ideal overjet, retraction of upper and lower Reduce protrusion of upper and lower lips
incisors for correction of proclination, correction of
Class III canine relation on the right side
Transverse Correction of crossbite tendency in the left canine Expect correction of chin deviation by
region by co‑ordination of arches, correction of midline elimination of dental occlusal interferences
discrepancy by asymmetric retraction mechanics
Vertical Establish adequate overbite ‑
The patient was advised to wear the removable the treatment. The right and the left buccal segment
retainers for two years with periodic check‑up every finished with a Class I molar and canine relationship.
6 months. All displacements and crossbites were corrected by
Complications encountered during treatment
the end of the treatment. No occlusal wear facets were
noted with mutually protected occlusion and canine
Difficulties were encountered in transverse co‑ordination
guided excursive movements established [Figure 33].
of arches, which was corrected in the upper with
A consonant smile arc was achieved and smile esthetics
dental expansion from an expanded archwire
was significantly improved along with an orthogonal
(0.019 × 0.025 SS) and posterior negative root torque
facial profile [Figure 34].
added to the wire to prevent palatal cusp hang. The
rolling in effect of molars in the lower arch due to the Lateral cephalogram reveals normal inclinations
retraction force was counteracted by adding expansion of maxillary and mandibular incisors and Class I
to the archwire (0.019 × 0.025 SS) and positive root molar and canine relation with an orthogonal facial
torque in the posterior segment. profile [Figures 35‑37 and Table 14]. OPG reveals
Results achieved
The case was finished with Class I incisor relationship
with normal overjet and overbite of 2 mm. The upper
and lower dental midlines matched at the end of
Figure 32: In‑treatment intra‑oral photographs Figure 33: Posttreatment intra‑oral photographs
Figure 34: Posttreatment extraoral photographs Figure 35: Posttreatment extra‑oral radiographs
Table 17: Section II: Treatment sequence and biomechanical plan [Figures 31 and 32]
Maxilla Mandible
Bonding of the upper arch (MBT ‑ 0.022 slot, ceramic) and initiate Bonding of lower arch (MBT ‑ 0.022 slot, ceramic) and initiate leveling
leveling and alignment with 0.016, 0.018, and 0.016×0.022 Niti wiresand alignment with 0.016, 0.018, and 0.016×0.022 Niti wires
Continue leveling and alignment with 0.019×0.025 Niti wire, Continue leveling and alignment with 0.019×0.025 Niti wire,
followed by placement of posted 0.019×0.025 SS wires for followed by placement of posted 0.019×0.025 SS wires for
symmetrical space closure asymmetrical space closure
Continue closure of the upper space with e‑chain on posted Buccal shelf orthodontic bone screws of 12 mm length placed in the
0.019×0.025 SS wires and anchorage from 1st and 2nd molars right lower buccal shelf region and immediate loading done with
e‑chain delivering a force of about 300 G for asymmetrical retraction
of the right buccal segment to correct the dental midline and develop
adequate overjet
After space closure, dental arch expansion done with expanded Full arch distalization was continued on the right side till Class
archwire (0.019×0.025 SS) and posterior negative root torque added I molar and canine relation was attained. The archwire was
to the wire, to coordinate the arch form and accommodate the lower periodically checked for transverse co‑ordination of arches
arch within the upper, Class II elastic support was provided on the
left side ‑ to maintain the Class I canine relation
Postspace closure and dental arch expansion, the arch was Postdistalization and space closure ‑ consolidation of arch was done,
consolidated with continuous ligature wire, and 0.012 Niti wire was and the same 0.019×0.025 SS wire was kept for extended period to
placed to aid in the settling process aid in ideal root parallelism
Figure 36: Posttreatment lateral cephalometric tracing
good root divergence of the maxillary and mandibular

Figure 37: Superimposition on the SN plane
dentition which would attribute to the stability of
the treatment results achieved and no signs of root
Declaration of patient consent
resorption [Figure 35].
The author certify that he have obtained all
Critical appraisal appropriate patient consent forms. In the form the
Although the results from an orthodontic point of patients have given their consent for their images
view looks promising and relapse is not expected and other clinical information to be reported in the
as the patient is past her growth phase, however, as journal. The patients understand that their names and
a new modality of treatment a long‑term follow‑up initials will not be published and due efforts will be
will actually determine the success achieved. The made to conceal their identity, but anonymity cannot
over‑all functional perspective also needs to be taken be guaranteed.
care along with long‑term follow‑up and health
of the temporomandibular joint. In the lower arch Acknowledgment
when retracting the lower dentition in thin gingival The author would like to acknowledge the efforts of his
biotype, it is advisable to invert the (−6° torque) colleagues from the orthodontic fraternity – Dr. Digant
lower anterior brackets, this reduces the chances of Thakkar (Rajkot, Gujarat), Dr. Bhavna Virang (Indore,
gingival recession and keeps the roots within the bone. Madhya Pradesh), and Dr. Ankita Lohia (Kolkata, West
However, in this case it was not required as the lower Bengal) toward compilation of data and adding valuable
incisors were proclined with adequate bone support. inputs to the article.
The case selection, the biomechanics, and appreciating Financial support and sponsorship
the anatomic limitations would still remain as some
Nil.
of the important perspectives for achieving the final
objective. Conflicts of interest
There are no conflicts of interest.
Conclusion
The aim of any new clinical protocol is to improve the References
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Taipei, Taiwan: Yong Chieh; 2007.
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Infra-Zygomatic Crest and Buccal Shelf - Orthodont

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Invited Submission: JIOS 50th Year Commemorative Issue

Infra-Zygomatic Crest and Buccal Shelf - Orthodontic Bone Screws:

© 2018 Journal of Indian Orthodontic Society | Published by Wolters Kluwer ‑ Medknow S127

Concepts of Placement of Bone Screws

For placement of bone screws in the BS area of mandible

Biomechanical Perspectives and Arch

Figure 9: Limits of mandibular distalization Figure 10: Pretreatment intra‑oral photographs

Figure 11: Pretreatment extra‑oral photographs Figure 12: Pretreatment extra‑oral radiographs

Table 3: Smile analysis

Table 4: Intra‑oral analysis Table 6: Comparison of cephalometric parameters pre‑

Figure 13: Pretreatment lateral cephalometric tracing Figure 14: Treatment planning

Table 7: Problem list

Table 8: Treatment objectives

Figure 16: In‑treatment orthopantomogram

Figure 15: In‑treatment intra‑oral photographs

Figure 18: In‑treatment intra‑oral photographs

Figure 17: In‑treatment intra‑oral photographs

Figure 20: In‑treatment intra‑oral photographs

Figure 19: In‑treatment intra‑oral photographs

Figure 22: Posttreatment extraoral photographs

Figure 21: Posttreatment intra‑oral photographs

Figure 23: Posttreatment extra‑oral radiographs Figure 24: Posttreatment lateral cephalometric tracing

Figure 25: Superimposition on the SN plane

Figure 26: Pretreatment extra‑oral photographs

Figure 27: Pretreatment intra‑oral photographs Figure 28: Pretreatment extra‑oral radiographs

Table 9: Section II: Treatment sequence and biomechanical plan

Table 11: Smile analysis

Table 12: Intra‑oral analysis

Table 15: Problem list

Table 16: Treatment objectives

Figure 32: In‑treatment intra‑oral photographs Figure 33: Posttreatment intra‑oral photographs

Figure 34: Posttreatment extraoral photographs Figure 35: Posttreatment extra‑oral radiographs

Figure 36: Posttreatment lateral cephalometric tracing

good root divergence of the maxillary and mandibular

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