CASE REPORT

Treatment of facial asymmetry and severe

midline deviation with orthodontic
mini-implants
Min-Ho Jung
Seoul, South Korea

This case report describes the treatment of a 29-year-old woman with facial asymmetry and 2 hopeless teeth.
Her lower dental midline was shifted to the left side, and the mandibular left second molar would need to be ex-
tracted because of severe caries. The maxillary right second premolar was root rest, and the upper dental midline
was shifted to the right side. Because of the patient's asymmetry and Class III skeletal pattern, a severe Class III
relationship in the right canine region and lingual crossbite in the left side was observed. She did not want jaw
surgery. The mandibular right first premolar, 2 hopeless teeth, and maxillary left second premolar were ex-
tracted, and orthodontic mini-implants were used to correct the dental midline, crossbite, and crowding. The
mandibular left third molar was moved to the second molar extraction space by using orthodontic mini-
implant anchorage. Adequate functional and esthetic results were obtained. Correction of the crossbite on the
left side could improve facial asymmetry by changing the drape of the overlying lips. (Am J Orthod
Dentofacial Orthop 2021;160:312-24)

A
symmetry is a common finding in the craniofa-
cial region1 and often causes occlusal problems
like midline deviation and crossbite. If the de-
gree of facial asymmetry is severe, it is better to improve
the problem through orthodontic decompensation and
asymmetric jaw surgery.2 In comparison, if the asymme-
try is mild, it may be difficult for the patient to agree to
surgery, and occlusal problems may need to be corrected
through orthodontic treatment alone. To achieve proper
occlusion while conducting the necessary asymmetrical
movement, anchorage control is very important. In
most patients, it is difficult to improve facial asymmetry
without orthognathic surgery, but in some patients, it
can be improved significantly by orthodontic treatment
alone.3,4
Some orthodontic patients have a missing
second molar because of severe caries. If the patient's
third molar is healthy, protraction of the third molar
From the Department of Orthodontic, Dental Research Institute and School of
Dentistry, Seoul National University, Seoul, South Korea; Private practice, Seoul,
Korea
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Min-Ho Jung, HONORS Orthodontics, 3rd Fl, Tae-
nam B/D, Cham-won Ro 3Gil 40, Seo-cho Gu, Seoul 06510, South Korea;
e-mail, fortit@chol.com.
Submitted, February 2020; revised and accepted, May 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.05.019
312
into the missing space may be considered rather than
implant placement and third molar extraction. In such
a case, particularly when the retraction of anterior
teeth is not required, anchorage becomes a significant
problem.
The introduction of orthodontic mini-implants
(OMIs) made it possible to obtain absolute anchorage.5
Asymmetric tooth movement or molar protraction can
be achieved without patient cooperation,6,7 and the
scope of orthodontic treatment has become much wider.
This case report describes asymmetric mandibular
tooth movement in a patient with facial asymmetry
who was treated with OMIs to improve the midline devi-
ation and crossbite. The hopeless mandibular left
second molar was extracted, the third molar was pro-
tracted, and the patient's occlusal problem was success-
fully corrected with adequate OMI anchorage.
DIAGNOSIS AND ETIOLOGY
A 29-year-old woman sought treatment for her chief
complaints of facial asymmetry and poor occlusion. Her
chin was deviated to the left side because of overgrowth
of the right side, and lip canting was observed (Figs 1-3).
In the posteroanterior (PA) cephalogram, based on the
crista galli–anterior nasal spine line, menton was located
to the left of the midline about 4.7 mm (Table I, Fig 4, B).
The mandibular ramus and body lengths were signifi-
cantly different from one another, but the occlusal plane
Jung
Fig 1. Pretreatment photographs.
canting was mild (0.5 ; Fig 4, B). The interpupillary line
and commissure line were not parallel to each other
(Fig 4, C).
Lingual crossbite was observed in the left premolar
area because of jaw asymmetry and Class III tendency.
As the mandibular left first molar was tilted lingually
by natural dental compensation, there was no crossbite
in the left first molar area. Because of the patient's asym-
metry and Class III skeletal pattern, a severe Class III rela-
tionship in the right canine region was also observed. In
the right molar area, the Class I molar relationship was
shown because of the forward movement of the maxil-
lary right first molar toward the second premolar space.
The patient did not have any temporomandibular joint
symptoms. The bilateral manual manipulation tech-
nique was used to evaluate condyle position,8 and the
American Journal of Orthodontics and Dentofacial Orthopedics
313
incisor relationship did not show significant lateral devi-
ation during the manipulation procedure.
The maxillary right second premolar and mandibular
left second molar were root rest because of severe caries.
In the maxillary right second premolar area, the alveolar
bone recession was observed on the panoramic radio-
graph. The upper dental midline was shifted to the right
side because the anterior teeth were moved toward the
root rest. Separately, the lower midline was shifted to
the left because of mandibular asymmetry. The nose
dorsum was slightly curved. In addition, nasion, subna-
sale, and labrale superius were not on a straight line, and
it was difficult to evaluate the amount of lateral
displacement of the dental midline. In a frontal facial
photograph with the soft tissue nasion–subnasale line,
the upper dental midline was located 1.5 mm to the right
August 2021  Vol 160  Issue 2
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Fig 2. Pretreatment dental casts.
side (Fig 4, D). But in a PA cephalogram with a crista
galli–anterior nasal spine line, it was located about
0.8 mm to the right side (Fig 4, B).
The upper midline was located at the interproximal
surface of the mandibular right central and lateral inci-
sors. Overbite and overjet were within normal limits
(2.5 mm and 2.5 mm), and a mild to moderate degree
of crowding was observed in both arches. The patient
did not have any specific medical or dental history.
Her vertical skeletal pattern was normal (Bjork sum,
399.1 ; Facial height ratio, 60.5) (Table II), and her
sagittal pattern was mild Class III (ANB, 0.6 ). Maxillary
and mandibular incisors showed a slight lingual inclina-
tion. Mild lower lip protrusion with lip incompetency
was noted on the facial photograph (lower lip to the
esthetic line, 2.1 mm).
On a panoramic radiograph, a horizontally impacted
mandibular right third molar and mesially inclined
mandibular left third molar were observed. The maxillary
right second premolar space was almost closed by
tipping and migration of adjacent teeth.
TREATMENT OBJECTIVES
Because the patient's main concern was facial asym-
metry and poor occlusion, the objectives of treatment
were to improve facial asymmetry and lingual crossbite,
correct the midline deviation, establish a Class I canine
relationship, improve the crossbite on the left side, and
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Jung
close the space of the 2 root rest areas. Correction of
crowding and improvement of the lip profile were also
required.
TREATMENT ALTERNATIVES
To solve the patient's chief complaint of asymmetry,
2-jaw surgery combined with orthodontic treatment was
deemed the best option. At the initial examination, she
displayed 3-dimensional asymmetry. Her mandibular
ramus and body length were longer on the right side,
and significant lip canting was observed. These skeletal
discrepancies cannot be corrected by orthodontic treat-
ment alone. However, she refused jaw surgery because of
fear and concern about the side effects. It was explained
and emphasized that, without jaw surgery, her facial
asymmetry cannot be improved, but she did not change
her mind. Thus, after further consultation with the pa-
tient, it was decided to attempt to improve the occlusion
and midline without facial asymmetry correction using
orthodontic treatment alone.
Extraction of the 2 root rest was inevitable. To correct
the upper dental midline and crowding, maxillary left
second premolar extraction was required. In the mandib-
ular arch, more than 3 mm of incisor movement to the
right side and improvement of moderate crowding
(arch length discrepancy, 4.0 mm) were necessary. In
other words, a large amount of tooth movement to the
right was required in the mandibular anterior teeth.
Jung 315

Fig 3. Pretreatment radiographs.

Implant placement in the mandibular left

Table I. Pretreatment posteroanterior cephalometric
second molar space was recommended because a large
measurements
amount of space was left in that region, and the mandib-
Pretreatment ular anterior teeth had to be moved to the right, which
Rt Co-Ag 72.6 could have made it more difficult to close the extraction
Lt Co-Ag 67.5 space. However, the patient wanted to close the
Rt Ag-Me 60.1
second molar space through a third molar protraction.
Lt Ag-Me 52.9
Rt Ag-MSL 49.2 To accomplish such an effect, an additional OMI was
Lt Ag-MSL 49.0 needed to protract the third molar (Fig 5). It was ex-
MSL-Me 4.7 plained to the patient that the treatment plan was very
Rt, right; Lt, left; Co, condylion; Ag, antegonial notch; Me, menton;
complicated even without third molar protraction and
MSL, midsagittal line (crista galli–anterior nasal spine). would be too time-consuming if third molar protraction
was included. The patient finally elected to undergo or-
Mandibular right first premolar extraction with thodontic space closure of the second molar space by the
anchorage reinforcement seemed to be indicated. outlined molar protraction.

American Journal of Orthodontics and Dentofacial Orthopedics August 2021  Vol 160  Issue 2
316 Jung

Fig 4. A, Tracing of pretreatment lateral cephalogram. B, Tracing of posteroanterior cephalogram. The

mandibular ramus (Co, condylion; Ag, antegonion) and body (Ag; menton, Me) length, the distance
from Ag to the midsagittal reference line (MSL; CG, crista galli; ANS, anterior nasal spine), and MSL
to Me distance were measured (Table I). C, The angle between soft tissue nasion–subnasale line
(NSL, red) and interpupillary line (yellow) was 92.0 . The angle between NSL and commissure line
(blue) was 87.4 . D, Upper dental midline was located 1.5 mm to the right side of NSL (blue).

Table II. Changes in cephalometric measurements

Pretreatment Posttreatment Postretention
Bjork sum ( ) 399.1 397.3 397.6
Facial height ratio (%) 60.5 61.7 61.6
ANB ( ) 0.6 0.6 0.5
A to N perpendicular (mm) 1.6 1.6 1.6
Pog to N perpendicular (mm) 2.9 1.2 1.2
U1 to FH ( ) 109.8 105.7 105.7
U1 to SN ( ) 100.1 96.0 95.9
L1 to A pog (mm) 4.1 0.2 0.3
IMPA ( ) 83.2 79.7 79.5
Interincisal angle ( ) 135.9 145.7 145.8
Nasolabial angle ( ) 102.2 103.5 103.8
Upper lip to Esthetic line (mm) 0.5 3.1 3.4
Lower lip to Esthetic line (mm) 2.1 1.4 1.4

Note. Bjort sum, Saddle angle + articular angle + gonial angle.

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Jung 317

Fig 5. Extraction of the 2 root rest (green, maxillary right second premolar and mandibular left
second molar) was unavoidable. To correct crowding and midline deviation, maxillary left second pre-
molar and mandibular right first premolar extractions (red) were required. To reinforce the anchorage,
OMIs were planned in the lower right posterior and lower left anterior alveolar bone. Green arrow, the
direction of tooth movement; dotted line, nasion–subnasale line.

Fig 6. Posttreatment photographs.

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318
Fig 7. Posttreatment dental casts.
TREATMENT PROGRESS
Because the patient wanted to use ceramic brackets,
0.022-in preadjusted edgewise ceramic brackets (Clarity;
3M Dental Products, Monrovia, Calif) were placed on
the labial surface of the whole dentition. The archwire
sequence progressed from 0.014-in nickel-titanium wire
to 0.019 3 0.025-in stainless steel working wire. Acrylic
bonded bite planes were used in the central incisors to pre-
vent overbite change and minimize the occlusal interfer-
ence during uprighting and protraction of the mandibular
left third molar. Occlusal equilibration in the third molar
was also performed during leveling. Root rest and premolar
extractions were conducted during initial leveling.
At the final stage of leveling, 2 OMIs (Mplant U2;
diameter, 1.5 mm; length, 7.1 mm; BioMaterials Korea,
Inc, Seoul, South Korea) were placed on the buccal alve-
olar bone between the mandibular right first and
second molars and between the mandibular left canine
and first premolar. After a working wire was placed, a
force was applied to close all the extraction space.
During protraction of the mandibular left third
molar, tip backbend, and low-level force (about 100 g
of force),9 were used to minimize mesial tipping. After
correcting the midline and closing all extraction spaces,
archwire adjustments were conducted for finishing and
detailing purposes. To prevent lingual crossbite on the
left side, additional torque was given in the lower left
posterior region. In addition, a narrow mandibular arch-
wire and a wide maxillary archwire were used. The
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number of missed appointments was 3, and the total
treatment duration was 30 months.
Before bracket removal, maxillary and mandibular
lingual fixed retainers were placed. After bracket
removal, the patient was given a circumferential retainer
for the maxillary arch and a Hawley retainer for the
mandibular arch. The instructions to the patient
included full-time retainer use for 6 months after de-
bonding and then nights only for 2 years.
TREATMENT RESULTS
Posttreatment intraoral photographs (Fig 6) showed
adequate overbite and overjet, a Class I canine relation-
ship, corrected midline deviation, and well-aligned teeth.
Mild gingival inflammation and white spot lesions result-
ing from poor oral hygiene were observed. The maxillary
right first molar showed gingival recession because of
pretreatment bone recession in this area (Figs 7 and 8).
The patient was recommended to visit a periodontist
for consultation. Lip incompetency was improved, and
appropriate canine guidance was obtained. All the
extraction spaces were successfully closed. On the left
side, a Class II molar relationship was achieved. Maxillary
molars moved forward by the extraction space closure,
but the intermolar width was maintained (51.2 mm) us-
ing a wide form archwire. In the mandibular arch, inter-
premolar width (second premolar, 40.9 mm to 39.6 mm)
and intermolar width (44.6 mm to 44.3 mm) were
decreased by additional torque and the narrow archwire.
Jung
Fig 8. Posttreatment radiographs.
On the cephalometric superimposition tracing, the
incisors were retracted, and the upper and lower lip pro-
files were changed because of incisor retraction (Fig 5,
A). The mandibular plane was closed about 1.8 , and
Pogonion moved forward about 1.7 mm.
Although the amount of the menton deviation was
not changed significantly in the PA cephalogram (Fig 9,
B; 4.7-4.6 mm), lip canting was decreased (Fig 9, C),
and the dental midline was improved (Fig 9, D). To
evaluate lip asymmetry, according to a previous study,4
using a vertical line from the midpoint of the base of
the nose (the middistance between the inner outline
of the nostrils) through the midpoint of the philtrum,
lower lip asymmetry was evaluated by the percentage
of area of the right and left lower lip. Pretreatment
American Journal of Orthodontics and Dentofacial Orthopedics
319
lower left segment area was 53.20% (Fig 9, E) and
posttreatment lower left segment area was 50.57%
(Fig 9, F).
After 4 years and 6 months of retention, she re-
turned for a check-up. The occlusion was stable,
and a slight relapse of the midline deviation was
observed (Figs 10-12). Although a mild gingival
recession was noted, the overbite, overjet, and
buccal occlusion were well-maintained. In the lateral
cephalogram, there were no significant changes dur-
ing the retention period (Table II).
DISCUSSION
On the lower right side, a large amount of mandibular
incisor movement was required to treat midline
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Fig 9. A, Craniofacial, maxillary, and mandibular superimposition composite tracing of lateral cephalo-
grams at pretreatment (black) and posttreatment (red). B, Midsagittal reference line (MSL) to menton
(Me) distance was not changed significantly (4.7-4.6 mm). C, After treatment, the angle between NSL
(red) and interpupillary line (yellow) was 92.1 , and the angle between NSL and commissure line (blue)
was 89.6 . Lip canting was decreased. D, The upper and lower midline coincides, and it fits well with
NSL. E, To evaluate the lip asymmetry, using the midpoint of the base of the nose–philtrum line,4 the left
and right areas of the lower lip were measured. Pretreatment lower left segment area (yellow) showed
53.20%. F, Posttreatment lower left segment area (yellow) was 50.57%.

deviation and crowding. Absolute anchorage was
needed. On the contrary, the lower left side required
third molar protraction without distal movement of
the first molar. After introducing OMIs as an orthodontic
anchorage source, many studies have been published
regarding their effects in various procedures, including
incisor retraction,10,11 whole-arch retraction,12,13 intru-
sion,14 and molar protraction.15
In this patient, the OMIs were positioned between the
mandibular right first and second molars and between
the mandibular left canine and first premolar. On the
right side, the buccal shelf area was used because this
area does not have the risk of root contact,16,17 whereas
interradicular alveolar bone was used on the left side.
Mandibular anterior teeth retraction and third molar
protraction were completed without significant
anchorage loss. The severely deviated dental midline
was successfully corrected without jaw surgery. Without
the use of OMIs, the success of such tooth movements is
unlikely.
Protraction of the second molar into the first molar
extraction space has been reported several times,7,15,18
but protraction of the third molar into the
second molar extraction space is rare. Regardless, the
possible problems during molar protraction are similar
and include tipping, vertical change, and width change.
Such side effects occur because the force vector
cannot pass the center of resistance. When pulling the
second molar forward, some patients have sufficient
attached gingiva to easily position the force near the

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Jung
Fig 10. Postretention photographs, 4.5 years into retention.
center of resistance. Because such treatment is impos-
sible in third molar protraction, molar tipping or
whole-arch rotation can be produced (Fig 13, A).19
Because the occlusal force acting on the posterior teeth
helps prevent molar tipping and extrusion if you use a tip
backbend and light force, side effects can be prevented
in most patients.
On the lower right side, incisor retraction using OMI
was performed. Because such a movement sometimes
produces a counterclockwise rotation (Fig 13, B),20 the
acrylic bite planes were bonded in central incisors (the
so-called bite turbo) at the initial leveling stage at the
level of the pretreatment overbite.20 Biteplanes also
reduce occlusal interference that can occur during molar
uprighting.
Usually, premolar extraction treatment does not
change the mandibular plane significantly, but some
of the patients may show mandibular plane rotation. A
recent systematic review showed that in extraction
American Journal of Orthodontics and Dentofacial Orthopedics
321
patients, the standard deviation of the mandibular plane
angle change during treatment was from 1.7 to 9.8 .21
In this patient, about 1.8 of counterclockwise mandib-
ular plane rotation was observed. The exact cause is un-
known, but it seems necessary to remember that slight
rotational changes may occur during treatment.
When the current patient refused to undergo jaw sur-
gery, she was informed that her facial asymmetry could
not be improved without such a procedure. However,
after debonding, a significant improvement of facial
asymmetry was observed. Given that orthodontic treat-
ment cannot change the size or shape of the jaw bone,
it is clear that these improvements are not because of
skeletal changes.
To correct the crossbite on the left side, the mandib-
ular canine and premolars moved inward, and maxillary
premolars moved outward by archwire adjustment. In
this regard, one can easily see the difference in arch
form by comparing the pretreatment and posttreatment
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322
Fig 11. Postretention dental casts.
occlusal intraoral photographs (Figs 1 and 6). Previous
research showed that correction of the unilateral cross-
bite improved lip asymmetry.3 In this study, the lower
lip surface area of the crossbite side was significantly
improved (from 56.85% to 52.12%) by orthodontic
treatment. The improved amount of lip asymmetry was
smaller (from 53.20% to 50.57%) in this patient, but it
seems to be because the lip asymmetry before treatment
was smaller. As the retraction of incisors produces lip
vermilion height decrease,22,23 outward position of teeth
in the crossbite side can make the lower lip larger, the
asymmetry more intense, and conversely, an inward po-
sition will make the lower lip smaller. It can be assumed
that the improvement of asymmetry by orthodontic
treatment can only be found in patients with unilateral
crossbite and mainly in lip vertical measurements. A
slight improvement in lip canting was also shown in
this patient, which is also thought to be due to vertical
lip changes.
Patient final occlusion can be established as a Class II
molar relationship. To obtain a proper Class I molar rela-
tionship, maxillary molar tubes usually have a 10 first-
order (molar offset) prescription.24 However, to acquire a
Class II molar relationship, 0 molar offset is necessary to
provide good occlusion.
Because the mandibular second molar tube of MBT
prescription has a 0 first-order bend and 10 torque,25,26
it can be an adequate substitute for the maxillary molars in
Class II molar finishing in patients. When different tubes
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are required for the right and left molars, more attention
should be paid to the bonding procedure to prevent poor
posttreatment occlusion or longer treatment because of re-
bonding. The posttreatment maxillary occlusal intraoral
photograph shows 10 molar offset on the right side and
0 molar offset on the left side.
CONCLUSIONS
This patient demonstrated successful correction of
midline discrepancy and third molar protraction using
OMI anchorage. Careful adjustment and use of appro-
priate biomechanics can successfully achieve a large
amount of asymmetric tooth movement. Correction of
the crossbite in the buccal segment may improve facial
asymmetry by changing the overlying lips.
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Fig 13. A, Because the pulling force vector cannot pass the center of resistance (CR) of the third molar,
molar tipping or whole-arch rotation can be produced during protraction. Occlusal force reduces the
possibility of these side effects. Blue circle, CR of the mandibular arch; red circle, CR of mandibular
molar; green arrow, force and moment acting on teeth by protraction force; blue arrow, moment by
tip backbend; yellow arrow, occlusal force. B, Incisor retraction using OMI may cause counterclockwise
rotation of the mandibular occlusal plane. Anterior biteplane reduces the possibility of bite deepening.
Blue circle, CR of the mandibular arch; red circle, CR of mandibular anterior teeth; green arrow, force
and moment acting on teeth by retraction force; yellow arrow, occlusal force by anterior biteplane.

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