CASE REPORT

En-masse retraction dependent on a temporary

skeletal anchorage device without posterior
bonding or banding in an adult with severe
bidentoalveolar protrusion: Seven years
posttreatment
Kyu-Rhim Chung,a Do-Min Jeong,b Seong-Hun Kim,c Young-Il Ko,d and Gerald Nelsone
Suwon, Seoul, and Uijongbu, South Korea, and San Francisco, Calif

This report describes a novel concept of en-masse retraction with temporary skeletal anchorage devices in place
of posterior bonding or banding. The patient was a Korean woman, aged 24 years 4 months, with a Class II
Division 1 malocclusion with severe mandibular anterior crowding. Both molars showed decalcification of the
cervical areas. Partial osseointegration-based C-implants and C-tube plates were placed bilaterally between
the maxillary second premolars and the first molars and in the posterior mandible. These temporary skeletal an-
chorage devices were used as independent appliances for full retraction of the maxillary and mandibular anterior
teeth 3-dimensionally without the assistance of posterior bonded appliances. The posterior occlusion was not
changed during treatment, and Class I occlusal relationships with optimal overjet and overbite were achieved.
The 7-year posttreatment records showed a stable result. (Am J Orthod Dentofacial Orthop 2012;141:484-94)

A
familiar concern during orthodontic treatment Numerous intraosseous anchors such as microscrews,
is to control Newton’s third law, the law of ac- miniplates, and palatal onplants have been introduced to
tion and reaction. Orthodontic force protocols reinforce anchorage and are preferred over dental or
such as Tweed’s philosophy of anchorage preparation extraoral anchorage when loss of any anchorage is un-
and the level anchorage system have been suggested wanted.4-6 Even though intraosseous anchors enable
to maintain or minimize any change in the molar clinicians to move the teeth without extraoral appliances,
positions in maximum anchorage cases.1,2 However, they are typically used as anchorage support for the
tooth-borne anchorage inevitably slips even with the ap- posterior teeth, bearing orthodontic appliances, which
plication of complicated mechanics or supplementary bring the usual risks of decalcification, periodontal side
appliances to control anchorage.3 effects, and the need to close the remaining band space.
We present a treatment protocol called biocreative
a
Professor and chairman, Department of Orthodontics, School of Medicine, Ajou therapy, which provides carefully controlled retraction of
University, Suwon, Korea.
b
the anterior teeth in 3 planes without the assistance
Director, Division of Periodontology, Department of Dentistry, National Medical
Center of Korea, Seoul, Korea.
of bonded or banded anchor teeth.7-11 The use of
c
Associate professor, Department of Orthodontics, College of Dentistry, Kyung the osseointegrated C-implant allows the application
Hee University, Seoul, Korea.
d
complex retraction forces (torque and intrusion) without
Private practice, Uijongbu, Korea.
e
Clinical professor, Division of Orthodontics, Department of Orofacial Science,
the need for posterior bands or brackets.9-14 This
University of California at San Francisco. treatment method is excellent when 100% anchorage is
The authors report no commercial, proprietary, or financial interest in the prod- needed in patients with dental caries, severe periodontal
ucts or companies described in this article.
Presented in part before the European Orthodontic Society Congress on June 7,
disease, or missing teeth.
2004, in Aahrus, Denmark. Supported by a grant from Kyung Hee University.
Reprint requests to: Seong-Hun Kim, Department of Orthodontics, College of DIAGNOSIS AND ETIOLOGY
Dentistry, Kyung Hee University, #1 Hoegi-dong, Dongdaemun-gu, Seoul
130-701, Republic of Korea; e-mail, bravortho@hanmail.net. A woman, aged 24 years 4 months, came with a com-
Submitted, April 2010; revised and accepted, June 2010. plaint of poor appearance caused by protruding maxil-
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists. lary and mandibular anterior teeth and a gummy smile
doi:10.1016/j.ajodo.2010.06.028 tendency. The intraoral examination showed a Class II
484
Chung et al
Fig 1. Pretreatment extraoral and intraoral photographs.
malocclusion with bidentoalveolar protrusion, midline
discrepancy, and severe crowding of the anterior teeth
(Figs 1 and 2). Decalcification on the bucco-cervical
areas of both molars was found in the intraoral examina-
tion. The cephalometric analysis showed a skeletal Class
II pattern with an ANB angle of 8 , and excessive procli-
nation of the maxillary and mandibular incisors (U1-NA
angle, 32 ; L1-NB angle, 39 ; interincisal angle, 102 )
(Fig 3, Table).
TREATMENT OBJECTIVES
The treatment objectives based on the results of the
cephalometric and study model analyses were to (1)
camouflage the skeletal malocclusion by retraction of
the anterior dentition after extracting all first premolars,
(2) correct the molar and canine relationships to a Class I
relationship with mutually protected canine guidance,
(3) achieve optimal overjet and overbite, and (4) improve
the facial balance.
American Journal of Orthodontics and Dentofacial Orthopedics
485
TREATMENT ALTERNATIVES
A headgear treatment option for anchorage support
was discussed, but the patient was a clerk and rejected
this treatment option. All treatment plans required the
extraction of all first premolars. Based on these objec-
tives, 3 treatment options were proposed. The first alter-
native was to perform an anterior segmental osteotomy
under general anesthesia. However, the patient refused
the surgical treatment option and requested full retrac-
tion of the maxillary and mandibular anterior teeth by
using the first premolar extraction spaces with conven-
tional orthodontic treatment.
Thus, en-masse retraction by using temporary skele-
tal anchorage devices with 2 alternatives was presented
to the patient: (1) retract the anterior teeth with conven-
tional mini-implants as anchorage support by reinforc-
ing the bonded or banded posterior anchorage teeth
during anterior retraction, or (2) use temporary skeletal
anchorage devices as independent appliances for
April 2012  Vol 141  Issue 4
486 Chung et al

Fig 2. Pretreatment study models.

Table. Cephalometric measurements

Average 7 years
(female)* Pretreatment Posttreatment retention
SNA ( ) 81.6 83 83 82
SNB ( ) 79.2 75 75 75
ANB ( ) 2.4 8 8 7
PFH/AFH (%) 66.8 57.3 58.0 57.1
SN-OP ( ) 17.9 22 26 26
FH-UI ( ) 116.0 125 101 101
FMA ( ) 24.3 35 35 35
IMPA ( ) 95.9 99 89 89
FMIA ( ) 59.8 46 56 56
UL to E-plane 0.9 6 3 2
(mm)
LL to E-plane 0.6 7 3 3
(mm)
Interincisal 123.8 102 135 134
angle ( )
U1-NA (mm) 7.3 9 0 1
U1-NA ( ) 25.3 32 8 9
L1 To NB 7.9 11 9 9
(mm)
L1-NB ( ) 28.4 39 30 30
SN-PP ( ) 10.2 12 12 10

*For Korean women, data from Korean Association of Orthodontists.23

anterior alignment and retraction without the assistance

Fig 3. Pretreatment lateral cephalogram. of bonded or banded posterior anchorage teeth.15
After en-masse retraction, conventional orthodontic

April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al 487

Fig 4. Decrowding of the 6 mandibular anterior teeth by using 0.016 3 0.022-in stainless steel segment
archwire (with soldered hook) inserted in the miniplate hole and Class I elastics between the distal
extension of the archwire and the soldered hook.

Fig 5. Treatment progress intraoral photographs (left side: mirror images are not converted): A and B,
maxillary first premolar extractions and 0.016 3 0.022-in stainless steel utility archwire and 0.25-in,
3.5-oz elastics to both dentitions; C-E, 0.9-mm beta-titanium alloy overlay archwire was delivered for
mandibular anterior intrusion immediately after decrowding; F, maxillary and mandibular soldered
hooks on the 0.018 3 0.025-in stainless steel archwire and power chain for en-masse retraction.

treatment would be performed on the posterior denti- TREATMENT PROGRESS

tion for detailing. The third treatment plan was selected
because no molar banding or bonding during en-masse
retraction would allow good oral hygiene, considering
the decalcification areas of both molars, and since the
posterior occlusion was excellent.
Treatment was preceded by placement of C-tube
plates (prototype made of pure gold casting) on the
buccal cortical plate of the mandible (Fig 4). These
miniplates have a 0.9-mm diameter hole to accept an
archwire and can be used when mini-implants are

American Journal of Orthodontics and Dentofacial Orthopedics April 2012  Vol 141  Issue 4
488
Fig 6. Treatment progress intraoral photographs (mandibular occlusal views): A, treatment started; B,
1 month; C, 2 months; D, 4 months after active treatment.
inappropriate (proximity of sinus or nerve, bone loss, or
root proximation). We first placed 0.022 3 0.028-in
preadjusted brackets on the 6 mandibular anterior
teeth, followed by the placement of a 0.016 3
0.022-in stainless steel archwire appliance between
the anterior teeth and the miniplate hole. We applied
traction to the canines with 0.25-in, 3.5-oz elastics
for anterior alignment. One month later, we placed 2
C-implants (CIMPLANT, Seoul, Korea), 1.8 mm in di-
ameter and 8.5 mm in length. The screw surfaces of
these temporary skeletal anchorage devices are sand
blasted with a large grit and acid etched. They were in-
serted into the interseptal bone between the maxillary
second premolar and first molar. After 4 weeks of heal-
ing, maxillary en-masse retraction was started (Fig 5,
A and B).
The initial archwire of this treatment protocol is usu-
ally a 0.016 3 0.022-in stainless steel wire with a vertical
step. If necessary to control torque during retraction,
one can use either a 0.017 3 0.025-in or a 0.018 3
0.025-in stainless steel wire. The force magnitudes of
0.25-in elastics are 2.5 to 3.5 oz for retraction of each
canine and 4.5 oz for en-masse retraction. Immediately
after mandibular anterior alignment, a 0.9-mm diameter
beta-titanium alloy overlay archwire was added for ante-
rior intrusion (Fig 5, C-E). Retraction of the maxillary
and mandibular anterior teeth was done with 0.018 3
0.025-in stainless steel wires with soldered brass wire
hooks (length, 7-9 mm). After the en-masse retraction,
a tooth positioner was used for a month for finishing.
April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al
Retention was provided by maxillary and mandibular
fixed retainers. The treatment change in the mandibular
dentition is shown in Figure 6. It took 21 months to treat
this patient.
TREATMENT RESULTS
After treatment, the occlusion was in a Class I canine
relationship with coincident midlines, proper interdigita-
tion, and good alignment. Ideal overjet and overbite, and
facial balance were achieved (Figs 7 and 8). The
posttreatment facial photographs showed great im-
provement of facial esthetics, since significant dental
protrusion was corrected. The incisors were not pro-
cumbent. The cephalometric analysis showed a slight
downward and backward mandibular movement as well
as intrusion and retraction of the maxillary anterior
teeth (Fig 9). The FMA did not change during the treat-
ment period (35 ). The occlusal plane changed a little after
treatment because of the intrusion of the mandibular an-
terior teeth and a slight extrusion of the posterior teeth
(SN to OP angle, from 22 to 26 ). Both the maxillary in-
cisors and the mandibular incisors were retracted signifi-
cantly (FH-U1 angle, from 125 to 101 ; maxillary incisor
to NA distance, from 9 to 1 mm; maxillary incisor to NA
angle, from 32 to 8 ; IMPA, from 99 to 89 ; FMIA,
from 46 to 56 ; mandibular incisor to NB distance,
from 11 to 9 mm; and mandibular incisor to NB angle,
from 39 to 30 ). The lips were competent in repose (up-
per lip to E-plane, from 6 to 3 mm; lower lip to E-plane,
Chung et al
Fig 7. Posttreatment extraoral and intraoral photographs.
from 7 to 3 mm). The interincisal angle was improved to
the normal range (from 102 to 135 ). The ANB did not
change during treatment (SNA, 83 ; SNB, 75 ). More
root retraction would have also retracted Point A.
The posterior facial height/anterior facial height ratio
changed a little during treatment (from 57.3% to
58.0%). The 6 maxillary anterior teeth were intruded
and retracted successfully by 2 C-implants. The treat-
ment result was quite acceptable, and the patient was
pleased with it, even though extraction spaces remained
(Fig 7). Retention continued for 11months after reten-
tion, and all temporary skeletal anchorage devices were
removed without complications. We removed the maxil-
lary fixed retainer and recommended a maxillary circum-
ferential retainer only at night. Figures 10 and 11 show
the maintenance of the treatment result after 7 years of
retention.
The extraction space closed without additional treat-
ment during the retention period, and a maxillary
canine-to-canine lingual bonded retainer was applied
at the patient’s request. Also, the patient’s 7-year reten-
tion intraoral photos showed dramatically positive
American Journal of Orthodontics and Dentofacial Orthopedics
489
gingival migration after treatment without additional
free gingival graft surgery. The pretreatment, treatment
progress, and posttreatment panoramic radiographs are
shown in Figure 12.
DISCUSSION
Improvements in implant orthodontics have made
their use possible as anchorage in orthodontic patients.
Many companies are now producing smaller and more
versatile mini-implants with various designs. Orthodon-
tic screws expand the horizons of orthodontic treatment,
because they allow treatment to proceed successfully
with virtually no anchorage loss and minimal patient
cooperation.
The type of temporary skeletal anchorage device used
here can provide 100% anchorage for bodily retraction
and intrusion without banding or bonding of the poste-
rior teeth.8,15-17 This is because the C-implant is
available with a tube to receive the archwire, and the
osseointegration potential allows heavy, rotational,
and dynamic loading.
April 2012  Vol 141  Issue 4
490 Chung et al

Fig 8. Posttreatment study models.

Fig 9. Posttreatment lateral cephalogram and superimposed tracings. Black line, pretreatment; red
line, posttreatment.

During traditional orthodontic treatment with full periodontal health before treatment is not ideal.18
fixed appliances in adults, retraction and intrusion sig- Once posterior bands are removed, remaining band
nificantly affect posterior dental anchorage and can space can be troublesome to fully close, with a risk of
take a toll on periodontal health, especially when the food impaction. If the patient has good posterior

April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al
Fig 10. Seven-year retention extraoral and intraoral photographs.
occlusion before treatment, the described biocreative
therapy allows retraction and intrusion without disturb-
ing the posterior occlusion.7,15 This can be invaluable for
an adult patient with bridges or crowns in the posterior
segments. Treatment can proceed without the need
for removing or altering the bridgework. Patients
with periodontal compromise in the posterior segments
are also ideal for biocreative therapy, since the
periodontium is also not disturbed during treatment
and extraordinary home care is avoided. Treatment
time is shorter than with conventional treatment; this
reduces the risk to the posterior dentition and support
tissues.
This treatment protocol is excellent when maximum
retraction is desired. Traditional full fixed therapy is still
suited for moderate retraction cases. Despite no banding
or bonding on the posterior teeth in our patient, minor
vertical and horizontal mesial movements of the poste-
rior teeth were noted. These movements might have
been caused by the effect of the anterior biteplate, which
American Journal of Orthodontics and Dentofacial Orthopedics
491
allowed disengagement of the posterior teeth during re-
traction of the anterior teeth. The cephalometric study of
Kim et al7 included 17 similarly treated patients and
showed that the maxillary molars had mesial movement
(PTV-U6, 0.74 6 1.01 mm; P \0.01), extrusion (PP-U6,
0.72 6 0.91 mm; P \0.01), and mesial tipping (SN-U6,
2.01 6 2.28 ; P \0.05). Also, the mandibular molars
showed a slight extrusion during en-masse retraction
(MP-L6, 0.86 6 0.92 mm; P \0.01). The anchorage
loss observed in their study was comparable with tradi-
tional methods of achieving maximum anchorage.
Brackets were attached to the maxillary anterior and
the mandibular dentitions, and 0.016 3 0.022-in stain-
less steel utility archwires were used to retract both an-
terior dentitions despite a large mandibular curve of
Spee. Sequential ligation on the anterior brackets in
our patient showed similar effects as sequential tooth
movement in Tweed-Merrifield treatment mechanics.
We applied gable bends on the utility archwires during
anterior retraction for anterior torque control
April 2012  Vol 141  Issue 4
492 Chung et al

Fig 11. Seven-year retention lateral cephalogram and superimposed tracing. Black line, posttreat-
ment; red line, retention.

Fig 12. Panoramic radiographs: A, pretreatment; B, 5 months after active treatment; C, 9 months after
active treatment; D, 13 months after active treatment; E, posttreatment; F, 7 years retention.

April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al
(biocreative therapy type I technique).10,11 Maxillary
C-implants and mandibular C-tube plates also endured
the heavy and dynamic forces during the orthodontic
treatment periods.
Interestingly, the patient’s 7-year retention photos
show the residual space closure and excellent occlusal
stability without additional fixed appliance treatment.
We applied the circumferential retainer with a slight ac-
tivation in the labial bow area after removing the maxil-
lary lingual fixed retainer in month 11 of retention. This
activation facilitated closure of the residual extraction
space. One more important finding was that this pa-
tient’s gingival recession tendency in the mandibular
right central incisor showed dramatic improvement
during the 7-year retention period. She received no ad-
ditional periodontal treatment (eg, free gingival graft-
ing), only conscientious home care. The mandibular
anterior teeth moved into the alveolar bone during
alignment. As a balanced occlusion was produced,
trauma from the occlusion disappeared after treatment.
This might have contributed to the improvement in the
attached gingiva. Clinical caution is warranted in cases
of adult anterior protrusion. The risk of fenestration is
increased with insufficient bone support and bone
remodeling.19,20 Some reports have recommended an
anterior segmental osteotomy in the mandibular
anterior dentition under local anesthesia to reduce this
risk.21,22
There is ongoing research on biocreative therapy in
the permanent dentition and its effects on arch form
and stability during the posttreatment period. Further
research is needed to evaluate this minor vertical and
sagittal change in posterior teeth during treatment with-
out tooth banding or bonding.
Some indications for considering biocreative ther-
apy would be maximum or absolute anchorage, bi-
dentoalveolar protrusion, severe dental crowding,
anterior spacing, and Class II anterior protrusion
with good molar interdigitation, severe dental caries
on anchorage teeth, extensively restored anchorage
teeth, compromised periodontal status of posterior
teeth, or edentulous posterior dentition. For better
retention after treatment, we recommend both a lin-
gual fixed retainer and a removable retainer, and, for
better cooperation, teaching the patient to practice
pronunciation.
CONCLUSIONS
Biocreative therapy in the permanent dentition can
be used for patients who need maximal or absolute
anchorage such as for severe crowding, bialveolar
protrusion, anterior protrusion, dental disease,
American Journal of Orthodontics and Dentofacial Orthopedics
493
extensive restorations, or periodontal compromise in
the anchor teeth.
Further research and studies would help clinicians to
understand the guidelines for treating adult patients
with systemic complications, to evaluate the first premo-
lar extraction effects with these treatment mechanics,
and to combine this new system with other orthodontic
treatment mechanics.
REFERENCES
1. Klontz H. Tweed-Merrifield sequential directional force treatment.
Semin Orthod 1996;2:254-67.
2. Root TL. The level anchorage system for correction of orthodontic
malocclusions. Am J Orthod 1981;80:395-410.
3. Melsen B, Verna C. A rational approach to orthodontic anchorage.
Prog Orthod 1999;1:10-22.
4. Kyung HM, Park HS, Bae SM, Sung JH, Kim IB. Development of
orthodontic micro-implants for intraoral anchorage. J Clin Orthod
2003;37:321-8.
5. Kim SH, Lee KB, Chung KR, Nelson G, Kim TW. Severe bimax-
illary protrusion with adult periodontitis treated by corticotomy
and compression osteogenesis. Korean J Orthod 2009;39:
54-65.
6. Moon CH, Lee JS, Lee HS, Choi JH. Non-surgical treatment and
retention of open bite in adult patients with orthodontic
mini-implants. Korean J Orthod 2009;39:402-19.
7. Kim SH, Hwang YS, Ferreira A, Chung KR. Analysis of temporary
skeletal anchorage devices used for en-masse retraction: a pre-
liminary study. Am J Orthod Dentofacial Orthop 2009;136:
268-76.
8. Chung KR, Kim SH, Kook YA. C-orthodontic micro implant
as a unique skeletal anchorage. J Clin Orthod 2004;38:
478-86.
9. Chung KR, Cho JH, Kim SH, Kook YA, Cozzani M. Unusual extrac-
tion treatment in Class II Division 1 malocclusion. Angle Orthod
2007;77:155-66.
10. Chung KR, Kim SH, Kook YA, Son JH. Anterior torque
control using partial osseointegrated mini-implants: biocrea-
tive therapy type I technique. World J Orthod 2008;9:
95-104.
11. Chung KR, Kim SH, Kook YA, Choo H. Anterior torque control us-
ing partial osseointegrated mini-implants: biocreative therapy
type II technique. World J Orthod 2008;9:105-13.
12. Kim SH, Lee SJ, Cho IS, Kim SK, Kim TW. Rotational resistance
of surface-treated mini-implants. Angle Orthod 2009;79:
899-907.
13. Jeon MS, Kang YG, Mo SS, Lee KH, Kook YA, Kim SH. Ef-
fects of surface treatment on the osseointegration potential
of orthodontic mini-implant. Korean J Orthod 2008;38:
328-36.
14. Mo SS, Kim SH, Kook YA, Jeong DM, Chung KR, Nelson G. Resis-
tance to immediate orthodontic loading of surface-treated mini-
implants. Angle Orthod 2010;80:123-9.
15. Chung KR, Nelson G, Kim SH, Kook YA. Severe bidentoalveolar
protrusion treated with orthodontic microimplant-dependent
en-masse retraction. Am J Orthod Dentofacial Orthop 2007;132:
105-15.
16. Chung KR, Kim YS, Linton JL, Lee YJ. The miniplate with
the tube for skeletal anchorage. J Clin Orthod 2002;36:
407-12.
April 2012  Vol 141  Issue 4
494
17. Chung KR, Kim SH, Kang YG, Nelson G. Orthodontic miniplate
with tube as an efficient tool for borderline cases. Am J Orthod
Dentofacial Orthop 2011;139:551-62.
18. Boyd RL, Baumrind S. Periodontal considerations in the use of
bonds or bands on molars in adolescents and adults. Angle Orthod
1992;62:117-26.
19. Bollen AM. Effects of malocclusions and orthodontics on peri-
odontal health: evidence from a systematic review. J Dent Educ
2008;72:912-8.
20. Burket LW. The effects of orthodontic treatment on the soft
periodontal tissues. Am J Orthod 1963;49:660-71.
April 2012  Vol 141  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Chung et al
21. Chung KR, Kim SH, Lee BS. Speedy surgical orthodontic treatment
using temporary anchorage devices as an alternative to orthog-
nathic surgery. Am J Orthod Dentofacial Orthop 2009;135:
787-98.
22. Chung KR, Mitsugi M, Lee BS, Kanno T, Lee W, Kim SH. Speedy
surgical orthodontic treatment with skeletal anchorage in adults—
sagittal correction and open bite correction. J Oral Maxillofac Surg
2009;67:2130-48.
23. Korean Association of Orthodontists. Cephalometric norm of Ko-
rean adults with normal occlusion. Korea: Ji-Sung Publishing
Co.; 1998. p. 589-95.