Case Report

Nonsurgical synergistic full-arch vertical intrusion treatment of bimaxillary

protruded hyperdivergent skeletal Class II malocclusion using aligners
Tao Peia; Xueqin Baib

ABSTRACT

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A bone-borne full-arch vertical control strategy using miniscrews was deployed with aligners to
treat a case of skeletal hyperdivergent Class II malocclusion with bimaxillary protrusion. Miniscrews
were inserted in the posterior buccal and palatal regions and the anterior buccal region of the maxilla
to distribute vertical intrusive force through the upper arch by anchoring vertical elastics from the min-
iscrews to the aligners. Synergetic lower anterior intrusion was completed using bilateral posterior
miniscrews to counteract the extrusive force generated. Substantial full upper arch and lower anterior
vertical intrusion was achieved. In conjunction with en masse anterior-posterior retraction, synergetic
posterior and anterior vertical intrusion facilitated counterclockwise rotation of the mandible, creating
significant esthetic improvement. Anterior vertical elastics also provided flaring of the anterior teeth,
reducing the side effect of lingual tipping from en masse retraction, while successfully controlling
overbite and incisor torque during space closure. The bone-borne full-arch vertical intrusion strategy
can work well with aligners to address hyperdivergent skeletal Class II malocclusion with bimaxillary
protrusion. (Angle Orthod. 2024;94:462–472.)
KEY WORDS: Vertical intrusion; Hyperdivergent; Protrusion; Mini-implant; Miniscrews; Torque
control

INTRODUCTION mandible and increased lower facial height.1,2 Although

it is relatively reliable to perform orthognathic surgery,
Among the Asian population, protrusion is commonly
there are still debates on the effectiveness of skeletal
complicated by a hyperdivergent Class II skeletal pat-
pattern correction5,6 and reluctance to undergo major
tern,1–4 which is characterized by excessive alveolar
surgical intervention.4,7
bone development. For such patients, facial esthetics
Miniscrews have been shown to be a reliable anchor-
are compromised, both by proclined anterior teeth and age device in sagittal profile reduction and are regularly
a prognathic maxilla, and aggravated by a retrognathic used in practice.2,8–11 For vertical reduction, use of min-
iscrews has been effective in open-bite correction.10,12
However, achieving significant synergetic true intrusion
a
Clinical Assistant Professor, Department of Orthodontics, of a full arch, which is necessary for substantial mandib-
Stomatology Center of Peking University Shenzhen Hospital; ular rotation and improvement of the facial profile required
Shenzhen Division of National Stomatological Clinical Research in correction of a hyperdivergent skeletal pattern, is diffi-
Center, Stamotology Clinical Research Center of Shenzhen, cult to implement in fixed orthodontics.9,13
Shenzhen, China.
b Previous studies have suggested that clear aligners
Clinical Professor, Department of Orthodontics, Stomatology
Center of Peking University Shenzhen Hospital; Shenzhen can be an effective treatment option for open bite with
Division of National Stomatological Clinical Research Center, a high mandibular plane angle by using bone-borne
Stomatology Clinical Research Center of Shenzhen, Shenzhen, posterior intrusion without anterior extrusion.11,14,15 This
China. indicates that appropriate combined application of minis-
Corresponding author: Dr Tao Pei, Clinical Assistant Professor, crews and aligners may potentially deliver promising
Department of Orthodontics, Stomatology Center of Peking
University Shenzhen Hospital, 1120 Lianhua Rd, Futian District,
results in treating bimaxillary protrusion in patients with a
Shenzhen, Guangdong Province 518036, China hyperdivergent skeletal pattern.
(e-mail: peitao@pkuszh.com) In this patient, miniscrews were used with aligners for
synergetic intrusion and en masse retraction for the upper
Accepted: March 2024. Submitted: November 2023.
Published Online: April 29, 2024 and lower arches with torque control of the anterior teeth,
Ó 2024 by The EH Angle Education and Research Foundation, in expectation of achieving a harmonious profile in both
Inc. the sagittal and vertical dimensions.

Angle Orthodontist, Vol 94, No 4, 2024 462 DOI: 10.2319/112923-790.1

SYNERGISTIC FULL-ARCH VERTICAL INTRUSION USING ALIGNERS 463

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Figure 1. Pretreatment facial and intraoral photographs.

Diagnosis and Etiology midlines were coincident with the facial midline. Both
arches were well aligned in ovoid arch forms with mild
A 24-year-old female presented with complaints of
dentoalveolar protrusion, retrusion of the chin, and dental discrepancies of 3.5-mm crowding in the upper
a gummy smile. Clinical examination showed a con- arch and 3 mm in the lower arch. Lingual inclination of
vex facial profile with protruded teeth and retrusive #16 and #26 teeth was noted. Class I molar and canine
mandible, accompanied by excessive lower facial relationships were noted on the right side with mild dis-
height. In addition to an acute nasolabial angle and lip tal deviation, while an end-to-end Class II relationship
incompetence, moderate muscular tension (mentalis was observed on the left (Figure 2). Overjet was 4 mm,
strain) was indicated by a shallow labiomental groove and overbite was1 mm. There was 4 mm of gingival expo-
and chin fossa (Figure 1). The upper and lower dental sure during dynamic smile.

Figure 2. Pretreatment dental models.

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Table 1. Pretreatment and Posttreatment Cephalometric Analysis

Before
Measurements Normal Treatment Posttreatment Difference
SNA (°) 83.0 6 4.0 81.6 80.6 0.9
SNB (°) 80.0 6 3.0 73.5 75.8 2.2
ANB (°) 3.0 6 2.0 8.0 4.9 3.2
Wits (mm) 0.0 6 2.0 7.3 1.6 5.8
PP-GoGn (°) 21.0 6 4.0 38.1 31.5 6.6
OP-SN (°) 19.0 6 4.0 18.1 19.6 1.5
MP-SN (°) 33.0 6 4.0 48.3 42.3 6.1
FH-MP (°) 28.0 6 4.0 42.4 36.6 5.9
SGn-FH (°) 64.0 6 3.0 69.2 65.4 3.8

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U1-L1 (°) 127.0 6 9.0 113.6 131.7 18.1
U1-SN (°) 105.0 6 6.0 105.5 98.4 7.1
Figure 3. Pretreatment panoramic x ray.
U1-NA (mm) 4.0 6 2.0 6.0 1.0 5.1
U1-NA (°) 21.0 6 6.0 23.9 17.8 6.1
The panoramic radiograph showed horizontal impac- L1-NB (mm) 6.0 6 2.0 12.2 4.2 8.0
tion of the third molars (Figure 3). Lateral cephalometric L1-NB (°) 28.0 6 6.0 34.5 25.7 8.8
IMPA (°) 93.9 6 6.2 92.6 87.7 4.9
radiography in maximum intercuspation exhibited a G-Sn-Pg 0 (°) 6.4 6 8.8 23.8 13.2 10.6
hyperdivergent profile (FH-MP ¼ 42.4°, MP-SN ¼ G-Sn (HP) (mm) 5.3 6 4.6 0.7 0.9 0.3
48.3°), with a skeletal Class II relationship (ANB ¼ G-Pg 0 (HP) (mm) 6.8 6 5.2 25.4 12.0 13.4
8.0°, Wits ¼ 7.3 mm) and mandibular retrognathia Sn-Gn 0 -C (°) 98.5 6 9.0 113.3 105.5 7.8
(SNB ¼ 73.5°, soft tissue facial angle G-Sn-Pg 0 ¼
23.8°; Figure 4; Table 1). Bimaxillary protrusion was
also indicated by a decreased interincisal angle (U1- chosen, therefore, to reduce protrusion and improve
L1 ¼ 113.6°), with exaggerated labial proclination of the the lateral profile by extraction of four first premolars
upper (U1-NA ¼ 6.0 mm) and lower incisors (L1-NB ¼ and use of miniscrews as skeletal anchorage devices.
12.2 mm). Miniscrews were planned for use primarily during maxil-
lary sagittal retraction. Then to improve the vertical
Treatment Objectives hyperdivergent skeletal pattern, a strategy of minis-
The treatment objectives were to achieve alignment crew placement would be used in both arches for vertical
intrusion, by which substantial intrusion could be
and leveling of both arches, improve overjet and over-
achieved to allow counterclockwise rotation of the
bite, establish Class I relationships, attain optimal profile
mandible, in the hope of accomplishing vertical reduction
improvement, and avoid development of an open bite
and mandibular advancement.
and prevent temporomandibular joint (TMJ) problems
Camouflage could have been achieved by using the
during synergistic full-arch intrusion.
edgewise appliance. However, full-arch vertical control
is probably limited in transferring vertical force to the full
Treatment Alternatives
arch through an edgewise system, and it is also a less
Although it was recommended to perform orthog- esthetic treatment system.9,18,19
nathic surgery, decision making became complicated Therefore, the treatment agreed on was to camou-
when dealing with the hyperdivergent Class II skeletal flage the hyperdivergent Class II skeletal pattern using
pattern with bimaxillary protrusion.6,16,17 Consider- the Invisalign® Comprehensive Package (Align Technol-
ing the patient’s esthetic concerns and reluctance to ogy, Santa Clara, California), using miniscrews in both
accept surgery, a nonsurgical camouflage plan was the maxilla and mandible, which involved using six

Figure 4. Cephalometric radiograph and tracing (A, Pretreatment. B, Miniscrews installed. C, Posttreatment).

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Figure 5. Initial ClinCheck.

miniscrews in the anterior and posterior maxilla, and aspect between lateral incisor and canine roots until
two in the posterior mandibular region. Synergetic step 15, while retraction did not start until aligning and
intrusion was designed between anterior and poste- leveling was completed.
rior teeth in both the upper and lower dental arches to By tray 25, there was anticlockwise rotation of the
achieve anticlockwise rotation of the mandible. mandible by full-arch intrusion and improved molar
relationship bilaterally. However, retraction also resulted
Treatment Progress in premature contacts of the anterior teeth, which made
continuing space closure inadvisable until further level-
For the first stage, the G6 attachment system was
ing was achieved. Thereby, a timely refinement was
used with 47 aligners (Figure 5). At the early third scheduled.
step, two 2 3 10-mm miniscrews (Ormco, Brea, Calif) For the first refinement, 38 aligners were prescribed.
for the maxilla and two 1.4 3 8-mm miniscrews for the Horizontal attachments were bonded to improve reten-
mandible were placed buccally between the first molar tion and counteract the extrusive force generated from
and second premolar roots, designated for anterior anterior intrusion. To control torque of the anterior teeth,
retraction. The lower right miniscrew was relocated overcorrection was planned for torque and tip of the
between the molars after it loosened. Palatal minis- anterior teeth, while a 1-mm open bite was designed
crews (2 3 12 mm) were placed between the first and for deep bite overcorrection (Figure 7). To continue
second molar roots (Figure 6) by which initial vertical vertical intrusion, anterior elastics were attached,
intrusion was initiated by using cross-aligner surface switching from a direct bonded resin button to an
elastics anchored between the upper posterior minis- aligner half-cut bubble (Figure 8), which also helped
crews and the palatal miniscrew, delivering intrusive torque control of the anterior teeth. Horizontal elas-
force to the posterior teeth. Anterior intrusion minis- tics continued to the end of space closure, while a
crews (1.4 3 8 mm) were not inserted on the labial direct bonded resin button was placed on the buccal

Figure 6. All miniscrews installed with elastics.

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Figure 7. First refinement ClinCheck.

surface to attach elastics and maintain uprighting of incompetence, and the gummy smile were markedly
the lower canines. corrected (Figure 12).
After space closure, a final stage (Figure 9) with 33 Cephalometric analysis (Figure 13; Table 1) showed
aligners was planned for refinement. Conventional notable vertical skeletal improvement of MP-SN and
attachments were used to facilitate the refinement, FH-MP by 6.1° and 5.9, respectively. Vertical intrusion
and intrusive elastics were maintained for final intru- allowed mandibular advancement, as denoted by the
sion and leveling. For the last steps, light vertical decrease of ANB from 8.0° to 4.9° and an increase
elastics were applied between the upper and lower of SNB from 73.5° to 75.8°, with the Wits appraisal
posterior teeth to achieve intercuspation and occlu- decreased by 5.8 mm. Dental movement also resulted
sal contact. Complete correction of posterior overin- in a 1.5° change in OP-SN, denoting that equilibrium
trusion in the upper arch was intentionally not achieved was reestablished between the dental arches fol-
and left to compensate for potential vertical relapse dur- lowing intrusion and retraction. Similarly, the procli-
ing retention. nation of incisors was also reduced to normal levels,
For all stages, the patient was required to change as indicated by a 6.1° angular and 5.1-mm linear
aligners every 10 days. At the end of treatment, maxillary decrease in U1-NA as well as 8.8° and 8.0 mm, respec-
and mandibular aligner retainers were used to stabilize tively, in L1-NB.
the occlusion. As a result, the soft tissue profile exhibited significant
improvement in both the sagittal and vertical dimen-
Treatment Results sions. This was shown in cephalometric superimpo-
sitions by a 10.6° decrease in facial angle (G-Sn-Pg 0 )
Upon final refinement, bilateral Class I molar and and a 13.4-mm advancement of soft tissue Pogonion in
canine relationships were achieved, accompanied G-Pg 0 (HP).
by ideal intercuspated occlusion with normal over- The condyles were distalized to centric relation after
bite and overjet (Figures 10 and 11). By using skel- mandibular rotation, thereby reestablishing centric occlu-
etally anchored full-arch intrusion and sagittal retraction sion in accordance with the change in the occlusal plane
of the anterior teeth, the extent of the anticipated (Figure 14).
resultant anticlockwise rotation of the mandible Superimposition of pretreatment and posttreatment
and reduction of dental protrusion was achieved. models (Figure 15; Table 2) showed an average of
Ultimately, the mandible advanced, and balanced 3.7 mm of intrusion of the upper incisors and 4.2 mm
facial esthetics were established. Muscle tension, lip of the posterior teeth, with 7.9 mm of sagittal retraction

Figure 8. Miniscrews and elastics in first refinement.

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Figure 9. Final refinement ClinCheck.

of the anterior teeth. Similarly, the lower incisors were reminder of the potential benefits of using a combina-
retracted by 6.3 mm and intruded 3.1 mm. tion of treatment modalities to achieve optimal results.
Follow-up conducted 1.5 years after treatment revealed Approximately 6° of reduction in MP-SN was achieved,
the overbite and overjet as well as molar and canine rela- which created significant advancement of the mandible
tionships being maintained and consistency of esthetics. and chin in the sagittal dimension. In addition to sagittal
The patient continues to wear clear retainers every day retraction of the anterior teeth, soft tissue esthetics was
and only removes them at night (Figure 16). significantly improved.
In this patient, the substantial intrusion and sagittal
DISCUSSION retraction achieved should be attributed primarily to
the use of skeletal anchorage in both the maxillary and
Conventional fixed orthodontics is not considered mandibular arches. Using multiple miniscrews allowed
capable of reducing a high mandibular plane angle and, vertical force to be applied on both the anterior and pos-
most of the time, causes steepening of the mandibular terior teeth simultaneously, achieving coordinated and
plane.8,9,18 Full-arch vertical control with miniscrews was synchronized equivalent intrusion of both the anterior
shown in recent years to decrease the vertical dimen- and posterior teeth. Synergetic intrusion of the lower
sion; however, limited change can be achieved.8,9,19 anterior teeth was also made possible using miniscrews
Different from controlling individual teeth using fixed inserted in the posterior region, which was achieved by
appliances, clear aligners encase the teeth of each uprighting the anterior teeth during en mass retraction
arch within a single orthodontic appliance, which and counteracted extrusion of the posterior teeth during
enables control of arch position and the teeth together leveling and anterior intrusion.
and can probably be more effective in achieving sub- In addition, substantial intrusion should be attributed
stantial intrusion to facilitate dramatic anticlockwise rota- to the combination usage of clear aligners. The unique
tion of the mandible. This case serves as an important nature of aligners allows application of intrusive force

Figure 10. Posttreatment dental models.

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468 PEI, BAI

Miniscrews were inserted both on the buccal and

lingual sides of the maxillary posterior teeth to facili-
tate intrusive force applied to the occlusal surfaces.8,9
As there was an expectation for significant intrusion
designed into the treatment plan, the apical region
between the first molar and second premolar labi-
ally, first and second molar palatally, as well as the
canine and lateral incisor labially were selected for
insertion to leave enough interroot space to protect
the roots from resorption.17 These locations were also
favorable due to bone quality, quantity, and thickness to

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achieve good primary stability of miniscrews, as reported
Figure 11. Posttreatment panoramic x ray. in the literature.1,8,17,20
Although the G6 system was developed by Invisalign
for use in extraction cases, especially for specific types
by elastics to the occlusal surface using labial and pal- of movement like tipping and inclination, its performance
atal miniscrews. Also, coverage by the aligners of the was questionable for substantial retraction as reported.21
full arch allows elastic force to be distributed and A deep curve of Spee and exaggerated overbite prompted
extended over at least three teeth by staggering pos- the use of conventional attachments in this case to provide
terior miniscrews on the buccal and palatal aspects more rigid control of teeth. The need for refinement and
for one tooth. By using elastics anchored from ante- timely refinement is inevitable and critical when using
rior miniscrews to the anterior labial aspect of the aligners, as accuracy of tooth movement can be between
aligners, vertical intrusive force was distributed to the 30% and 65% for different types of movement.10,15,20,21
full arch by the aligners. Also, labially anchored anterior In this case, conventional attachments provided enough
vertical force delivered a labial moment to help control extrusive force to resist anterior intrusion in the lower
the torque of anterior teeth, while also achieving signifi- arch, which was neutralized by posterior intrusive
cant vertical intrusion of the anterior teeth during their force created from the lower miniscrews, as shown
retraction.10,20,21 by superimpositions.

Figure 12. Posttreatment extraoral and intraoral photographs.

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Figure 13. Cephalometric superimposition between pretreatment (red) and posttreatment (blue).

It has been widely believed that the treatment period Extraction of premolars requires good control of retrac-
using aligners is longer than that of fixed orthodontics, tion as well as comprehensive vertical control throughout
especially for complex cases. However, recent studies the process, which significantly increases treatment
have challenged this notion, and treatment of patients complexity. However, with a multidimensional design
with high difficulty may not necessarily be prolonged, and sequencing of tooth movements, after two refine-
despite a probable increase in the need for refinement ments, teeth were effectively controlled, and treatment
restarts.10,14,22 This case may serve as a good example. time was appropriately compressed, resulting in a total

Figure 14. Three-dimensional reconstruction of condyle.

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Figure 15. Superimposition of pretreatment and posttreatment digital models (central incisor median point of cut edges before/after treatment;
first molar mesial buccal cups tip points before/after treatment).

active treatment time of 29 months. Proper treatment pattern has long been discussed.23,24 As seen in the
design, appropriate sequencing, and timely restarts current patient, excessive vertical growth of the pos-
can effectively improve treatment efficiency, and aligner terior dental arch can result in passive mandibular
treatment can achieve treatment times comparable with clockwise rotation and a decrease in overbite, lead-
fixed orthodontic treatment, even in cases with high diffi- ing to a lack of vertical overlap anteriorly and resul-
culty and complexity. tant dysfunction of incisor and canine guidance. In
Despite limited literature supporting a causal relation- addition, forward displacement of the coronoid pro-
ship between malocclusion and TMJ dysfunction (TMD) cesses could possibly take on more force than they
in recent years, the impact of a hyperdivergent skeletal are designated to handle, leading to joint problems.
Therefore, a comprehensive evaluation of all factors
Table 2. Three-Dimensional Movements of Central Incisors and contributing to TMD was necessary, which influenced
First Molarsa the decision to conduct full-arch vertical intrusion to
Upper Arch cause distal relocation of coronoid process to a more
11 21 16 26 Avg/CI Avg/FM normal position. Finally, by ensuring proper occlusion
and tooth alignment, the risk of joint problems can be
Sagittal 7.6 8.1 0.9 1.7 7.9 1.3
Vertical 3.7 3.8 3.9 4.4 3.7 4.2 minimized or even avoided altogether by orthodontic
Horizontal 0.2 0.3 0.4 2.4 0.3 1.0 treatment in certain cases.
Lower Arch
CONCLUSIONS
31 41 36 46 Avg/CI Avg/FM
Sagittal 6.4 6.2 1.5 2.0 6.3 1.7 •
Vertical 3.5 2.7 0.6 0.2 3.1 0.2
Using aligners and miniscrews, full-arch vertical
Horizontal 0.6 0.9 2.3 0.3 0.8 1.0 control can achieve significant synergetic intru-
a sion to achieve mandibular anticlockwise rotation,
Note: Negative denotes mesial moving in sagittal dimension,
extruding in vertical dimension, and left moving in horizontal dimension;
improve skeletal relationships, reestablish intermaxil-
Avg/CI average movement of central incisors; and Avg/FM average lary balance, and avoid TMJ problems for hyperdiver-
movement of first molars. gent Class II malocclusion.

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Figure 16. Extraoral and intraoral photographs after 18 months retention.

• Proper design, appropriate sequencing, and timely 5. Lin S-Y, Yu K-W, Lai T-t, Liu C-J, Hsu L-F. Orthodontic cor-
restarts can help aligners achieve treatment durations rection of bimaxillary protrusion with mini-screws in Class II
comparable with fixed orthodontics, even in such hyperdivergent patient. Taiwan J Orthod. 2019;31(2):6.
6. Rajandram RK, Ponnuthurai L, Mugunam K, Chan YS.
complex cases.
Management of bimaxillary protrusion. Oral Maxil Surg Clin.
• The treatment results and a 19-month follow-up period 2023;35(1):23–35.
confirmed the effectiveness of treatment and stability 7. Al-Bitar ZB, Al-Ahmad HT. Anxiety and post-traumatic stress
in the patient presented. symptoms in orthognathic surgery patients. Eur J Orthod. 2017;
39(1):92–97.
ACKNOWLEDGMENT 8. Lin J, Liou E, Bowman SJ. Simultaneous reduction in verti-
cal dimension and gummy smile using miniscrew anchor-
This report was supported by Shenzhen Clinical Research age. J Clin Orthod. 2010;44(3):157–170.
Center for Oral Disease (20210617170745001). 9. Wang Y, Zhou Y, Zhang J, Wang X. Long-term stability of
counterclockwise mandibular rotation by miniscrew-assisted
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Angle Orthodontist, Vol 94, No 4, 2024