IJOI 48 LIVE FROM THE MASTER

IZC Bone Screw Anchorage for Conservative

Treatment of Bimaxillary Crowding in an
Asymmetric Class II/I Subdivision 1 Malocclusion

Abstract
Introduction: A 23-year-old male presented for orthodontic consultation to evaluate chief complaints of severe crowding and
protrusive lips.

Diagnosis: Clinical and radiographic examination revealed a convex facial profile (G-Sn-Pg’ 19°), protrusive lips, hypermentalis
activity, coincident midlines, mandible deviation to the right, asymmetric Class II/I subdivision-right malocclusion, narrow arches,
7-8mm of crowding in each arch, and a relatively high mandibular plane angle (SN-MP 37°). The Discrepancy Index was 20 points.

Treatment: All permanent teeth were erupted except for horizontally impacted lower third molars. Following extraction of all four
third molars, a passive fixed self-ligating appliance was installed. Infrazygomatic crest (IZC) bone screws were inserted buccal to the
upper molars to provide posterior skeletal anchorage to retract both arches. Expansion of the constricted maxillary arch was initiated
with light buccal force, that was delivered with a circular-formed 0.016-in copper nickel titanium (CuNiTi) archwire. The bite was
opened with an anterior bite turbo, and all four buccal segments were differentially retracted, to correct intermaxillary crowding and
asymmetric Class II interdigitation, with IZC anchorage and Class III elastics. Third order correction and finishing were accomplished
with rectangular archwires and a root torquing auxiliary. Active treatment time was 26 months.

Outcomes: Excellent dental and periodontal results were achieved: Cast-Radiograph Evaluation of 21 and a Pink & White Esthetic
Score of 5. Lip protrusion and incompetent lips were corrected to the patient’s satisfaction, but there was a 2mm retraction and 2°
clockwise rotation of the mandible, that increased both the lower facial height (LFH) and facial convexity (FC).

Conclusions: Retrospective analysis indicated that the mandibular retrusion and clockwise rotation were related to extrusion of the
lower molars, and an undiagnosed sagittal slide in occlusion (CR to CO discrepancy), as evidenced by wear facets on the initial casts. (Int
J Orthod Implantol 2017;48:4-22)
Key words:
Asymmetric Class II/I, Subdivision 1 malocclusion, passive self-ligating appliance, extra-alveolar (E-A) bone screw anchorage,
infrazygomatic (IZC) miniscrew anchorage, anterior bite turbo, sagittal slide in occlusion, centric relation and centric occlusion
discrepancy, wear facets

History and Etiology

A 23-year-old male presented for orthodontic evaluation with two chief complaints: severe crowding
and protrusive lips. Clinical and radiographic evaluations showed a modest intermaxillary discrepancy
(ANB 4°) that was due to a slightly protrusive maxilla (SNA 83°) and slightly retrusive mandible (SNA 79°).
The convex facial profile (G-Sn-Pg’ 19°) was associated with increased lower facial height (60%), excessive
lip protrusion (2mm/3.5mm to the E-Line), and hypermentalis strain when the lips were closed (Fig. 1). This
morphologic pattern is commonly referred to as an increase in lower facial height (LFH) and/or an excessive

4
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

Dr. Ming-Jen Chang,

Lecturer, Beethoven Orthodontic Course (Left)
Dr. John Jin-Jong Lin,
Examiner of IJOI. Director of Jing-Jong Lin Orthodontic Clinic (Center)
Dr. W. Eugene Roberts,
Editor-in-chief, International Journal of Orthodontics & Implantology (Right)

vertical dimension of occlusion (VDO). An intraoral examination and study casts revealed canine and molar
relationships that were Class II on the right side and Class I on the left (Class II/I subdivision-right malocclusion).
Excessive overjet (6mm) was associated with a deep overbite (4mm), and there was 7-8mm of crowding in
each arch (Fig. 2). The dental and facial midlines were coincident, but the chin was deviated to the right (Fig. 1).

█ Fig. 1: Pre-treatment facial and intraoral photographs

5
IJOI 48 LIVE FROM THE MASTER

The pre-treatment cephalometric radiograph

confirmed a retrusive facial pattern (G-Sn-Pg’ 19°, SNA
83°, SNB 79°, ANB 4°), with a high mandibular plane
angle (SN-MP 34°) (Fig. 3 & Table 1). The panoramic
radiograph ( Fig. 4 ) showed bilateral horizontal
impaction of the mandibular 3rd molars ( LR8 and
LL8 ). Three dimensional (3D ) imaging with cone-
beam computed tomography (CBCT) revealed the
proximity of the lower third molars to the inferior
mandibular canal (Fig. 5). Skeletal, dental and facial
analyses are detailed in the diagnosis section.

█ Fig. 2:
Pre-treatment dental models (casts) are marked with yellow The treatment of this asymmetric Class II/I Subdivision
arrows to show wear facets.
malocclusion with an increased VDO was a challenge
that was best managed with extra-alveolar (E-A) bone
screw (BS) anchorage.1-3

█ Fig. 3: Pre-treatment lateral cephalometric radiograph

6
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

█ Fig. 4: Pre-treatment panoramic radiograph

█ Fig. 5:
CBCT 3D imaging was used to evaluate the relationship between the lower third molar roots and the inferior alveolar canal
bilaterally.

The infrazygomatic crest (IZC) was an ideal site for • Facial asymmetry: In contrast to coincident facial and
temporary anchorage devices (TADs) to retract both dental midlines, the chin point is deviated to the right.
1,2
arches.
Dental:

• Buccal (canine and molar) relationships: Class II on

Diagnosis the left and Class I on the right.
• Overjet: 6mm
Skeletal:
• Overbite: 4mm (40%)
• Lower face is retrusive: SNA 83°, SNB 79°, and
• Crowding: 7mm in the upper arch and 8mm in the
ANB 4°
lower arch
• Mandibular plane angle is increased: SN-MP 34°,
• Third molars: LL8 and LR8 were horizontally impacted
FMA 27°

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IJOI 48 LIVE FROM THE MASTER

• Midlines: Dental and facial midlines were coincident 6. Facial esthetics: Retract the protrusive lips and establish
• Arch-forms: Constricted in both arches lip competence

Facial:
Treatment Alternatives
• Profile: Increased convexity (G-Sn-Pg’ 19°)
It is well established that symmetric or asymmetric
• Nasolabial Angle: Increased
extraction of premolars is the traditional approach
• Anterior-Posterior: Retrognathic mandible, maxilla for correction of a severely crowded dentition in
was within normal limits (WNL) an adult. However, the present patient preferred
• Protrusive Lips: 2mm/3mm to the E-Line a conservative ( non-extraction ) approach, but
• Hypermentalis Strain: With lips closed understood that arch expansion and TAD anchorage
were necessary. Since buccal segment retraction
T h e A m e r i c a n B o a r d o f O r t h o d o n t i c s ( AB O ) was required in each quadrant, extraction of all four
Discrepancy Index (DI) was 20 points as shown in the third molars was indicated.
subsequent worksheet 1.4
Comprehensive treatment was planned as specified
below. Install a full fixed, self-ligating orthodontic
Treatment Objectives appliance to align the dentition, level the arches,
1. Level and align both arches and reduce the overjet. Place 2x8mm stainless steel
(SS) IZC bone screws bilaterally to provide posterior
2. Correct overjet and overbite maxillary anchorage for intermaxillary retraction.
Use an anterior bite turbo to open the bite for
3. Retract the lips and control the VDO to relieve
retraction of the maxillary dentition with IZC bone
mentalis strain
screw anchorage to correct crowding, lip protrusion
4. Skeletal Relationships: Maintain the maxilla and and interdigitation discrepancies. Class III elastics
mandible in all three planes are indicated for retraction of the lower dentition
to correct crowding and the axial inclination of the
5. Maxillary and mandibular dentition: incisors. Following alignment, detail the occlusion
with finishing bends and intermaxillary elastics.
a. Nonextraction alignment of both arches
Remove fixed appliances and deliver clear overlay
b. Optimize the intermaxillary occlusion retainers for both arches.

c. Relieve bimaxillary crowding

d. Obtain an ideal overjet and overbite Treatment Progress

e. Obtain Class I canine and molar relationships Following CBCT confirmation that the lower 3 rd

8
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

1M

█ Fig. 6:
Upper arch retraction was initiated by applying a chain of elastics from each maxillary TAD to the corresponding upper first
premolar. Class III elastics were used, from the lower canines to upper 1st molars bilaterally, to resolve the anterior crowding.

molars were not impinging on the inferior alveolar first premolar (U4). Class III elastics (Quail 3/16-in 2-oz)
rd
nerve ( Fig. 5 ), all four 3 molars were extracted applied compressive force from the lower canines
prior to commencing orthodontic treatment. A to upper 1st molars bilaterally, to resolve the lower
full fixed 0.022-in slot Damon Q® bracket system anterior crowding (Fig. 6). Two months later, the Class
(Ormco, Glendora, CA) was used with archwires and III elastics were changed to Fox (1/4-in 3.5-oz).
auxiliaries supplied by the same manufacturer. All
brackets were standard torque except for the lower At four months (4M) into treatment, alignment of the
anteriors, where low torque brackets were used. upper arch was improving, but the maxilla was still
Initial archwires were 0.013-in CuNiTi in both arches. quite narrow (Fig. 8). The mandibular arch was well
A 2x8mm SS IZC miniscrew was installed buccal to aligned (Fig. 9) as the lower buccal segments were
the upper first and second molars, bilaterally (Figs. retracted. A 0.016-in CuNiTi archwire was circled on
6 and 7). Upper arch retraction was initiated at the a small mandrel to distort the arch-form in the form
start of treatment by applying a chain of elastics of a circle (Fig. 8), and then it was engaged in the
from each maxillary TAD to the corresponding upper maxillary brackets to expand the narrow maxillary
arch. Two buttons were bonded on the palatal side
of the upper right 2nd premolar (UR5) and 1st molar
(UR6) to attach a criss-cross elastic (Fox 1/4-in 3.5-oz)
to the lower right 2nd premolar (LR5) and 1st molar
(LR6) (Fig. 8). On the left buccal segments, Fox Class III
elastics were continued. One month later (5M), the
Class III elastics were increased to Kangaroo (3/16-in
4.5-oz).

█ Fig. 7:
2x8mm SS bone screws were installed the IZC bilaterally.

9
IJOI 48 LIVE FROM THE MASTER

4M

█ Fig. 8: In the 4th month, a circular form 0.016-in CuNiTi archwire was placed to expand the narrow maxillary arch.

4M

█ Fig. 9:
Four months (4M) into treatment, the crowded lower anteriors were aligned, and Class III elastics were discontinued as
documented in the Archwire Sequence Chart (Table 3).

In the 6th month of the treatment (6M), the upper bilaterally to close space as the buccal segments
archwire was changed to a 0.018x0.025-in CuNiTi. were retracted.
Class III elastics were used on the left side only
and changed to Fox. The upper arch retraction In the 15 th month of treatment ( 1 5 M ), both
mechanics were still engaged from the maxillary archwires were replaced with 0.014x0.025-in NiTi
TADs to the upper first premolars using power archwires. An anterior bite-turbo (BT) composed of
chains (Fig. 10). glass Ionomer cement5 was bonded on the lingual
surfaces of the upper central incisors. The BT( s )
th
In the 8 month, the archwires were changed to opened the bite, thereby providing an intrusive
a 0.016x0.022-in SS in the upper and 0.017x0.025- force on the upper and lower incisors. They also
in titanium-molybdenum alloy (TMA) in the lower. created a posterior open bite to facilitate full arch
Bracket repositioning was performed repeatedly as retraction. As the arches were leveled and aligned,
needed to correct axial inclinations in the buccal space was created distal to the upper left lateral
segments. Power chains were attached from incisor (UL2) by retracting the left buccal segment
the upper right central incisor to the first molar (Fig. 11).

10
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

6M

█ Fig. 10:
Six months (6M) into treatment, crowding in the maxillary arch was corrected by arch expansion and retraction of the buccal
segments with IZC anchorage.

15M

█ Fig. 11:
In the 15th month of treatment (15M), both arches were fitted with 0.014x0.025-in NiTi archwires. An occlusal bite-turbo (BT)
composed of glass ionomer cement was bonded on the lingual surfaces of the upper central incisors to correct anterior
deepbite and facilitate maxillary arch retraction.

In the 20th month (20M), the IZC bone screw on the 20M
left side became loose and was removed because
it was no longer needed ( Fig. 12 ). Three months
later ( 23M ), the upper archwire was changed to
0.016x0.025-in SS for expansion of the posterior
segments. Upper arch retraction mechanics were
continued on the right side with a power chain from
the TAD to the upper right first premolar (Fig. 13).

Cross elastics were applied from the buttons bonded

█ Fig. 12:
on the lingual surfaces of the LR4, LR6 and LR7 to the In the 20th month (20M), the left IZC miniscrew had been
buccal surfaces of the UR4, UR6 and UR7 (Fig. 14). removed.

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IJOI 48 LIVE FROM THE MASTER

23M The unilateral cross elastics on the right side helped

correct maxillary arch asymmetry as the buccal
segment was retracted. One month later (25M)
a torquing spring was placed on the upper right
lateral incisor to move the UR2 root labially, as the
maxillary arch was finished (Fig. 15). After 26 months
of treatment, all fixed appliances were removed.

█ Fig. 13: █ Fig. 15:

In the 23 rd month, the upper archwire was changed to A torquing spring auxiliary was placed on the upper right
0.016x0.025-in SS to expand of the posterior segments lateral incisor to move its root labially.
(above). Upper arch retraction of the right maxillary buccal
segment was continued.

24M

█ Fig. 14:
At twenty-four months (24M) into treatment, frontal and lateral intraoral photographs document progress (upper). Cross
elastics were applied from the buttons bonded on the lingual side of the lower teeth (lower right) to the buccal surface of their
antagonists (bottom left).

12
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

Results achieved Retention

Hawley retainers were delivered for both arches
Maxilla (all three planes):
to be worn full time for the first 6 months and
• A - P: Maintained nights only thereafter. Plaque control and retainer
• Vertical: Maintained maintenance instructions were provided.
• Transverse: Expanded with correction of asymmetry

Mandible (all three planes): Final evaluation of treatment

• A - P: Retracted (posterior rotation) There was a 2% increase in both LFH and FC that

• Vertical: Increased (posterior rotation) was associated with extrusion of the lower molars
(Fig. 20). The relatively longer, more retrusive facial
• Transverse: Maintained
pattern appeared to be a sequelae of the anterior
Maxillary Dentition BT( s ) used to correct the deepbite and facilitate
arch retraction ( Fig. 11 ). Despite the increase
• A - P: Retracted
in FC, there was an overall improvement in lip
• Vertical: Incisors intruded
protrusion, lip competence, dental alignment
• Inter-molar / Inter-canine Width: Increased with and functional occlusion ( Figs. 16-19 ). The final
correction of asymmetry alignment was assessed at 21 points with ABO Cast-
Radiograph Evaluation ( CRE ), 6 as documented in
Mandibular Dentition
the supplementary worksheet at the end of this
• A - P: Maintained report. Major residual discrepancies were noted in
• Vertical: Increased (molar extrusion) three categories: marginal ridges (6 points), occlusal
• Inter-molar / Inter-canine Width: Maintained / contacts ( 6 points ) and occlusal relationships on
Increased the right side (5 points). Overbite was reduced from
4 to 1mm, but the Class II discrepancy was not
Facial Esthetics: completely corrected on the right side. In addition,
• Posterior Rotation of the Mandible: Increased FC the mandibular second molars were tipped distally
(21°) and excessive LFH (62%) because of an inadequate root-distal moment in

• Lips: Retracted to improve facial balance the archwire. These axial inclination problems (Fig.
18 ) resulted in marginal ridges discrepancies in
• Mentalis Strain: Relieved by retracting the lips
the posterior segments ( Figs. 16 and 17 ). The Pink
• Lip protrusion: Improved
and White dental esthetic score was 5 points, as
• Facial Profile: More convex (Figs. 16-20) subsequently documented in worksheet, which is
consistent with the outcomes recommended by
Sarver and Yanosky.7

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IJOI 48 LIVE FROM THE MASTER

█ Fig. 16: Post-treatment facial and intraoral photographs

█ Fig. 17: Post-treatment dental models (casts) █ Fig. 18: Post-treatment panoramic radiograph

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 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

Discussion
Ast et al.8 examined 1413 high school students aged
15-18 years from upstate New York and found that
23.8% had Class II malocclusions, compared to 69.9%
with Class I malocclusions, which was a ratio of ~1:3.
The underlying etiology of Class II malocclusions was
originally thought to be genetic, based primarily on
racial and familial characteristics, but more recent
studies suggest that many malocclusions previously
thought to be genetic are actually acquired. 9-11
Environment can play an important role in the
development of certain types of malocclusions.
For example, the early loss of the maxillary second
deciduous molars or palatial ectopic eruption of
second premolars may result in mesial migration of
█ Fig. 19: Post-treatment lateral cephalometric radiograph

█ Fig. 20:
Superimposed cephalometric tracings show dentofacial changes over 26 months of treatment (red) compared to the pre-
treatment position (black). The anterior cranial base superimposition (left) documents the retraction of the protrusive lips
and opening of the VDO as the mandible rotated clockwise. The LFH increased and the mandible assumed a more posterior
posture (blue circle). The upper right superimposition on the maxilla shows the retraction of the dentition relative to the apical
base of bone. The lower left superimposition on the mandible reveals the extrusion of the mandibular molars. See text for
details.

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IJOI 48 LIVE FROM THE MASTER

the permanent molars.12 Furthermore, a persistent more protrusive when the lower lip is postured in
finger sucking habit increased overjet, the lower lip the overjet.15,17
may become trapped behind the maxillary incisors,
causing abnormal contraction of the mentalis muscle Facial esthetics is a critical consideration when
and other perioral muscles leading to uprighting considering extractions to alleviate crowding. Four
of lower incisors and labial tipping of maxillary permanent premolars, one in each quadrant, are
13
incisors. Another proposed etiology for functional commonly extracted to treat Class II malocclusion
types of malocclusion is mouth breathing, which in adults.16 In general, the skeletal features of a Class
may precipitate a low tongue posture and openbite II malocclusion are not the primary determinant for
14,15
as a result of nasal or adenoid obstruction. extractions. Crowding and differential anchorage
requirements are usually the deciding factor(s).
Class II division 2 malocclusion may be associated
with mandibular retrusion, maxillary protrusion, In recent decades, TADs have been increasingly
increased VDO, posterior positioning of the TMJ popular for managing difficult malocclusions in
16
fossa, and/or maxillary constriction. For Class II adults. 18,19 However, the interradicular position
division 1 malocclusion, maxillary incisors tend to be of the miniscrews, a high failure rate, and their

16
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

tendency to move when loaded has limited their retraction of the lower molars. Cephalometric
application for conservative treatment of skeletal superimposition on the mandible ( Fig. 20 ) shows
1-3
malocclusions, particularly when there is crowding. extrusion and distal tipping of the lower molars,
Skeletal orthodontic anchorage systems (TADs) can but no net retraction relative to the apical base of
provide adequate anchorage for management of bone. This is an illusion in a 2D cephalometric view
severe malocclusions without extensive patient (Fig. 19). The lower arch was expanded, so the molars
1-3
compliance. were distally tipped as shown in the post-treatment
panoramic radiograph (Fig. 18 ). There was no A-P
The present patient felt the convex facial profile change in the 2D cephalometric views because the
was acceptable, but excessive lip protrusion was arch was expanded, so its A-P length in the sagittal
undesirable ( Fig. 1 ). Correcting an Angle Class II/ plane was reduced (Fig. 20).
I subdivision malocclusion without extractions
requires retraction of a maxillary molar( s ). The Overall, the non-extraction approach using IZC
IZC is an ideal maxillary site for the placement of miniscrew anchorage produced good dental
1-2
orthodontic bone screws to retract both arches. alignment and reduced lip protrusion, but there was
an increase in the VDO as reflected by ~2° increase in
IZC miniscrews, positioned buccal to the maxillary the following: facial convexity, SNB and mandibular
molars, were an ideal solution for retracting the plane angle ( FMA ). These undesirable sequelae
1,2
upper arch and reducing bimaxillary protrusion. are consistent with two changes noted in the
Failure to completely correct the Class II relationship cephalometric tracings: 1. lower molars are extruded
on the right side was related to a lack of overjet after ~2mm in the mandibular superimposition (Fig. 20
the axial inclinations of the incisors was corrected. lower right ), and 2. the mandible moved distally
More retraction with IZC anchorage on the right ~2mm as it rotated posteriorly ~2° in the anterior
side would have resulted in a midline deviation cranial base superimposition (Fig. 20 left). The molar
and end-to-end incisal occlusion. Interproximal extrusion problem can be explained by the use of
reduction (IPR) of the enamel on the lower incisors anterior BTs ( Fig. 11 ). 5 The posterior displacement
and retraction with a chain of elastics to close IPR of the mandible during treatment suggests a
space was indicated to produce overjet for Class II discrepancy between centric relation ( C R ) and
correction of the right buccal segment. Once overjet centric occlusion (CO). There was no documentation
is created, IZC anchorage on the right side was ideal of a CR → CO shift in the initial examination, but the
for completing the Class II correction of the right pretreatment casts (Fig. 2) suggest it may have been
buccal segments. However, retraction of a maxillary a long-term problem. Wear facets are noted on the
segment to correct Class II occlusion requires distal inclines of the UR3 cusp and the buccal cusp
adequate overjet. of UR4 ( Fig. 6 ). Apparently, the patient habitually
positioned the mandible in a more anterior position,
The lower third molars were extracted prior to which may have been related to parafunction, and

17
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IJOI 48 LIVE FROM THE MASTER

the path of the anterior excursion of the mandible is References

evidenced by two wear facets (yellow arrows in Fig. 6). 1. Lin JJ. C reative Orthodontics Blending the Damon system &
TADs to manage difficult malocclusions. 2nd ed. Taipei: Yong
Chieh Co; 2010.
Intermaxillary elastics commonly extrude molars and
2. Huang TK, Chang CH, Roberts WE. Bimaxillary protrusion
increase the VDO because of the vertical component treated with miniscrews. Int J Orthod Implantol 2014;34:78-
of force. This problem can be avoided by using 89.
both maxillary and mandibular E-A bone screws for 3. Lin JJ. Treatment of severe class III with buccal shelf mini-
screws. News & Trends in Orthodontics 2010 Apr;18:4-15.
intra-alveolar force in each arch rather than relying
4. Cangialosi TJ, Riolo ML, Owens SE, Jr, Dykhouse VJ, Moffitt
on intermaxillary anchorage.1-3,10-12 For the present AH, Grubb JE, Greco PM, English JD, James RD. The ABO
patient, there is no documentary evidence that the discrepancy index: a measure of case complexity. Am J Orthod
Dentofacial Orthop 2004;125(3):270-8.
Class III elastics (Fig. 10) contributed to the increase
5. Mayes JH. Bite Turbos. New levels of bite-opening acceleration.
in the VDO. No extrusion of the maxillary molars Clinical Impression 1997;6:15-17.
were noted relative to the apical base of bone in 6. Casko JS, Vaden JL, Kokich VG, Damone J, James RD,
Cangialosi TJ, Riolo ML, Owens SE, Jr, Bills ED. Objective
the maxillary superimposition ( Fig. 20 upper right ) .
grading system for dental casts and panoramic radiographs.
Control of the expected upper molar extrusion was American Board of Orthodontics. Am J Orthod Dentofacial
apparently controlled by the vertical component of Orthop 1998;114(5):589-99.
7. Sarver DM, Yanosky M. Principles of cosmetic dentistry in
the IZC retracting force (Fig. 10).
orthodontics: part 2. Soft tissue laser technology and cosmetic
gingival contouring . Am J Orthod Dentofacial Orthop
2005;127:85-90.
Conclusions 8. Ast DB, Carlos JP, Cons DC. Prevalence and characteristics of
malocclusion among senior high school students in up-state
This challenging malocclusion (DI=20), was treated
New York. Am J Orthod 1965;51:437-445.
conservatively (without extractions) in 26 months 9. Roberts WE, Hartsfield JK Jr. Multidisciplinary management
to an excellent dental alignment ( CRE=21 ) with of congenital and acquired compensated malocclusions:
diagnosis, etiology and treatment planning. J Indiana Dent
relatively simple mechanics. IZC bone screw
Assoc 1997;76(2):42-53.
anchorage combined with Class III elastics were 10. Chang MJ, Chang CH, Roberts. Probable airway etiology for a
effective mechanics for intermaxillary retraction to severe Class III openbite malocclusion: conservative treatment
with extra-alveolar bone screws and intermaxillary elastics. Int
resolve crowding in both arches and to correct the J Orthod Implantol 2017;45:4-20.
asymmetric Class II molar relationship. However, 11. Lee A, Chang CH, Roberts WE. MIH-related loss of
mandibular molar extrusion and an apparent C O mandibular first molars resulted in an acquired Class II skeletal
malocclusion: conservatively treated with space closure on
→ C R discrepancy contributed to increased facial
one side and implant-supported prosthesis on the other. Int J
convexity, that was associated with a more posterior Orthod Implantol 2017;47:26-48.
position and clockwise rotation of the mandible. 12. Tseng LYL, Chang CH, R oberts WE. Di agno sis and
conservative treatment of skeletal Class III malocclusion with
anterior crossbite and asymmetric maxillary crowding. Am J
Orthod Dentofac Orthop 2016;149:555-66.
Acknowledgment 13. Lear CSC, Flanagan JB, Moorrees CFA. The frequency of
deglutination in man. Arch Oral Biol 1965;10:83-99.
Thanks to Mr. Paul Head for proofreading this article.

18
 IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48

14. Neto ACB, Saga AY, Pacheco AAR, Tanaka O. Therapeutic

approach to Class II, Division 1 malocclusion with maxillary
functional orthopedics. Dental Press J Orthod 2015;20(4):99-
125.
15. Rijpstra C, Lisson JA. Etiology of anterior open bite: a review. J
Orofac Orthop 2016 Jul;77(4):281-6.
16. Cleall JF, Begole EA. Diagnosis and treatment of class II
division 2 malocclusion. Angle Orthod 1982;52:38-60.
17. Weinstein S, Haack DC, Morris LY, Snyder BB, Attaway HE.
On the equilibrium theory of tooth position. Angle Orthod
1963;33(1):1-26.
18. Park HS, Lee SK, Kwon OW. Group distal movement of
teeth using microscrew implant anchorage. Angle Orthod
2005;75:602-9.
19. Park HS, Kwon TG, Sung JH. Nonextraction treatment with
microscrew implants. Angle Orthod 2004;74:539-49.

19
 DISCREPANCY INDEX WORKSHEET EXAM YEAR 2009
    
IJOI 48CASE
LIVE #FROM THE
1 MASTER
P(Rev.
ATIENT   CHAO-YUEN CHIU 
9/22/08) ABO ID# 96112
TOTAL D.I. SCORE 25

OVERJET LINGUAL POSTERIOR X-BITE

Discrepancy
1 Ð 3 mm. Index
0 mm. (edge-to-edge) =
= Worksheet
1 pt.
0 pts. 1 pt. per tooth Total = 20
DISCREPANCY
3.1 Ð 5 mm. INDEX
= 2WORKSHEET
pts. EXAM YEAR 2009
    
5.1 Ð 7 mm. = 3 pts.
�
C7.1 BUCCAL POSTERIOR
ABO ID# 96112 X-BITE
Ð 9# mm. 1
ASE P(Rev.
ATIENT   CHAO-YUEN CHIU 
= 9/22/08) 4 pts.
T>OTAL
9 mm. D.I. S CORE = 20 5 pts.
25
2 pts. per tooth Total = 02
Negative OJ (x-bite) 1 pt. per mm. per tooth =
OVERJET LINGUAL POSTERIOR X-BITE
CEPHALOMETRICS (See Instructions)
0 mm. (edge-to-edge) = 1 pt.
1 Ð 3 mm.Total == 0 pts. 5 1 pt. per tooth Total = 0
ANB ≥ 6¡ or ≤ -2¡ 0 = 4 pts.
3.1 Ð 5 mm. = 2 pts.
OVERBITE
5.1 Ð 7 mm. = 3 pts. 6mm BUCCAL POSTERIOR X-BITE
7.1 Ð 9 mm. = 4 pts.
Each degree < -2¡       x 1 pt. =      
>09Ðmm.
3 mm. == 5 0pts.
pts.
3.1 Ð 5 mm. = 2 pts. 2 pts.
Eachperdegree Total = x 1 pt. = 2     
tooth > 6¡      
5.1 Ð 7 mm. = mm. per
3 pts. 0
Negative OJ (x-bite) 1 pt. per tooth = 2 pt
Impinging (100%) = 5 pts. SN-MP
CEPHALOMETRICS (See Instructions)
Total
Total
=
= 55 5 ANB
≥ 38¡
6¡ or ≤> -2¡
= 2 pts.
≥ degree
Each 38¡ x 2 pts. = 4 pts.
=
OVERBITE
Each degree < -2¡       x 1 pt. =      
≤ 26¡ = 1 pt.
0ANTERIOR
Ð 3 mm. OPEN BITE= 0 pts.
3.1 Ð 5 mm. = 2 pts. 4mm Eachdegree
Each degree> <6¡26¡
      4 x 1xpt.
1 pt.
= =     4
5.1
0 mm. (edge-to-edge), 1 pt. per3tooth
Ð 7 mm. = pts.
Impinging
then 1 pt. per additional full mm.pts.
(100%) = 5 per tooth 1 to MP ≥ 99¡
SN-MP = 1 pt.
≥ 38¡ x 1 pt. = 2 pts.2
=
Total
Total == 25 0 Each degree > 99¡
Each degree > 38¡
2
x 2 pts. =

≤ 26¡ Total = = 1 pt. 0

8
LATERAL OPEN
ANTERIOR OPEN BITE
BITE
Each degree < 26¡ 4 x 1 pt. = 4
02mm.
pts. (edge-to-edge),
per mm. per tooth
1 pt. per tooth OTHER (See Instructions)

then 1 pt. per additional full mm. per tooth 1 to MP ≥ 99¡ teeth
Supernumerary       =x 1 pt.
1 pt.
=      
Total = 0      
Ankylosis
Each of perm.
degree > 99¡teeth 2 x 1 pt. 2 =      
=x 2 pts.
Total = 0
0 Anomalous morphology       x 2 pts. =      
CROWDING (only one arch) Impaction (except 3rd molars) x 2 pts. =
1 Ð 3 mm. OPEN BITE =
LATERAL 1 pt.
Midline discrepancy (≥3mm) Total =@ 2 pts.8 =      
Missing teeth (except 3rd molars)       x 1 pts. =
3.1 Ð 5 mm. = 2 pts. Missing teeth, congenital       x 2 pts. =      
25.1
pts.Ðper mm. per tooth =
7 mm. 4 pts. OTHER (See Instructions) 2
Spacing (4 or more, per arch)       x 2 pts. =
> 7 mm. = 7 pts. 2
Spacing (Mx cent. diastema ≥ 2mm)
Supernumerary teeth @ 2 pts.     
      x 1 pt. = =
Total
Total =
= 0
0
1
Tooth transposition
Ankylosis of perm. teeth       x 2xpts.
      2 pts. =      
=      
Skeletal asymmetry
Anomalous morphology (nonsurgical tx)
      x 2 pts. =2 =
@ 3 pts.     
CROWDING (only one arch) Addl. treatment
Impaction (except complexities
3rd molars)       x 2xpts. = =      
2 pts.
Midline discrepancy (≥3mm) @ 2 pts. =      
1OCCLUSION
Ð 3 mm. = 1 pt. Identify:
Missing teeth (except 3rd molars)       x 1 pts. =
3.1 Ð 5 Imm.
Class to end on == 2 0pts.
pts. Missing teeth, congenital       x 2 pts. =      
= = 0
5.1
EndÐ 7onmm.
Class II or III = = 4 2pts.
pts. per side       pts. 42
Spacing (4 or more, per arch) Total
      x 2 pts.
>Full
7 mm.Class II or III == 7 4pts.
pts. per side       pts. Spacing (Mx cent. diastema ≥ 2mm) @ 2 pts. = 2
Beyond Class II or III = 1 pt. per mm.       pts. Tooth transposition       x 2 pts. =      
Total = 17 additional Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Total = 8mm0(lower) Addl. treatment complexities       x 2 pts. =      
OCCLUSION Identify:
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side       pts. Total = 4
Full Class II or III = 4 pts.
4 pts. per side      
Beyond Class II or III = 1 pt. per mm.       pts.
additional

Total = 40
Full Class II (right)

20
 IBOI Cast-Radiograph Evaluation Occlusal Contacts
IZC Bone Screw Anchorage for Conservative Treatment of Bimaxillary Crowding IJOI 48
Case # Patient

Total Score: Occlusal Contacts

Cast-Radiograph Evaluation 6

����� Alignment/Rotations
Case # Patient

Total Score: 21
Alignment/Rotations

3 1 1 2
1
1 1

1 1
1

Marginal Ridges

Occlusal Relationships
Marginal Ridges
Occlusal Relationships
6
11

1
2 2 1
1

1
Buccolingual Inclination
2 Interproximal
1 1 1 Contacts
Interproximal Contacts
Buccolingual Inclination
0
1

Overjet
Overjet Root Angulation

0 0

1 1

INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with ÒXÓ. Second molars should be in occlusion.
in the white box. Mark extracted teeth with ÒXÓ. Second molars should be in occlusion.

21
IJOI 48 LIVE FROM THE MASTER

IBOI Pink & White Esthetic Score

Total Score: = 5
1. Pink Esthetic Score
Total =
2
5
4 1. M & D Papillae 0 1 2
6 53 4
5
62 35 14 2. Keratinized Gingiva 0 1 2
62 35 4
14
22 53 114 3. Curvature of Gingival Margin 0 1 2
2 3 1
2 3 1 4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

1. M & D Papilla 0 1 2

2. Keratinized Gingiva 0 1 2

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score ( for Micro-esthetics ) Total = 3

1. Midline 0 1 2

4 3 1 2. Incisor Curve 0 1 2
4 3 1
4 3 11 2 3. Axial Inclination (5°, 8°, 10°) 0 1 2
4 3 1 5 2 4. Contact Area (50%, 40%, 30%)
3 1 26 0 1 2
4 3 5 6
4 2 5 6 5. Tooth Proportion 0 1 2
2
2 6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5°, 8°, 10°) 0 1 2

4. Contact Area (50%, 40%, 30%) 0 1 2

5
5 5. Tooth Proportion 0 1 2
5
2
2 6. Tooth to Tooth Proportion 0 1 2
2

22