Combined use of microimplants and a self-made four-curvature torquing auxiliary arch to manage labial root fenestration of the maxillary incisors: A case report

Abstract

During orthodontic treatment, ensuring the safety of anterior teeth with exposed roots is crucial. Our report describes the case of a 19-years-old female patient who was treated at a local clinic for severe bimaxillary protrusion. The clinic physician extracted the patient’s seven premolars and one mandibular lateral incisor, resulting in failure of the orthodontic treatment. After this failed treatment at the local clinic, the patient presented to our hospital for follow-up treatment (second treatment). When the patient was transferred to our hospital, she still exhibited a skeletal Class II relationship (A point-nasion-B point angle (ANB): 12.5°) profile, and her anterior teeth were severely upright, with an initial U1-NA of −1.5° (normal value: 22.8° ± 5.7°). This value changed after treatment to 14.32° (normal value 22.8° ± 5.7°). Cone beam computed tomography showed that the roots of the anterior teeth had penetrated the labial cortical bone, and it was challenging to ensure the safety of the second treatment. In our patient, the roots of the anterior teeth safely entered the center of the maxilla, with the U1-NA changing from −1.5° to 11° after treatment with our self-made four-curvature torquing auxiliary arch. Moreover, root length did not change, and root absorption did not occur.

Keywords

Self-made four-curvature anterior tooth torque microimplant root maxillary

Introduction

Torque control is a key element in the extraction of the first premolars during orthodontic treatment. Although several methods for controlling the inclination of the incisors during retraction are available, there is no evidence regarding the advantages of some methods over those of others.¹ In addition to controlling the inclination of the incisors, the direction of the force vector can be modified during retraction in direct relation to the interaction of the orthodontic wire with the surface of the breech gap.^2,3 The traditional method involves application of torque force locally using stainless steel square wires. However, this method has limited efficiency. Bone fenestration caused by torque issues is a recurrent problem that is challenging to solve and prevent during orthodontic treatment.^2,4 Severe bone fenestration cannot be treated by applying force through wire torsion. The use of orthodontic mini-implants is one of the greatest achievements made in the field of orthodontics over the past 20 years. Therefore, in this case, we employed a combination of microimplants and a self-made four-curvature torquing auxiliary arch to manage labial root fenestration of the maxillary anterior teeth.^5,6

There were three main challenges in this case, as described below.^7,8 First, the patient had previously undergone orthodontic treatment involving the extraction of the seven first premolars and one mandibular lateral incisor. Second, her anterior teeth exhibited serious upright phenomenon, but showed bimaxillary protrusion. Third, the patient refused to undergo bone meal filling. Therefore, it was challenging to control the position of the maxillary anterior roots within the alveolar housing and correct the skeletal Class II relationship of the patient while ensuring anterior teeth safety.⁹ We proposed a nonsurgical treatment with bone meal filling using microimplants and a self-made four-curvature torquing auxiliary arch to assist in controlling molar anchorage and anterior torque. In our patient, the roots entered the center of the maxilla, length of the roots did not change, and anterior teeth and molars showed good occlusion. This case report intended to demonstrate the effectiveness of using a custom auxiliary arch combined with microimplants¹⁰ to control torque during traction of the anterior teeth.

Patient information

In July 2017, a young woman in her early 20s presented to the Department of Dentistry of Daping Hospital, Army Medical University, with chief complaints of missing seven first premolars and one mandibular lateral incisor, a severe protrusion profile, and a gummy smile (Figure 1). All patient details have been anonymized. Informed consent was obtained from the patient for study participation as well as publication of photographs. The reporting of this case conforms to the Case Report (CARE) guidelines.¹¹

Figure 1.

Pretreatment facial and intraoral photographs and panoramic radiographs.

Class II molar relationships with an overjet of 3.0 mm and a deep overbite of approximately 6 mm were diagnosed. The right maxillary and mandibular second molars showed locked occlusion. The maxillary dental midline almost coincided with the facial midline, and the mandibular dental midline had shifted 3.5 mm toward the right. No temporomandibular joint disease or remarkable skeletal asymmetry was observed. Dental caries, crowding, and periodontal and systemic diseases were not observed. The patient was healthy, with no medical, family, or psychosocial history, including any relevant genetic disorders.

Model analysis revealed maxillary and mandibular arch length discrepancies of −8 and −7 mm, respectively. Measurement data revealed Bolton’s indices of 82.0% and 88.0% for the anterior and overall ratios, respectively. Spee curve of the mandibular arch was 5.5 mm.

For the cone beam computed tomography (CBCT) examination, the patient was instructed to sit upright and close her teeth. The midsagittal plane was perpendicular to the floor and parallel to the Frankfort horizontal plane.¹² The patient was scanned using a GALILEOS Comfort system (Sirona, Germany). The rotation angle was 204°, scanning time was 14 s, and number of images taken for a single tooth was 200. The scanning range extended from the lower margin of the orbit to the chin. In total, 711 tomographic images were obtained following the scanning, and the data were exported in DICOM format. Furthermore, the CBCT images taken before, during, and after the treatment were imported into OnDemand3D software (Korea) for the measurement and analysis of the central incisors. The images showed that the apical region of the central incisors was closed, and no remarkable absorption was present. Measurements of crown–root length at the labial, middle, and palatal aspects showed no significant changes.

Cephalometric analysis was performed at every stage using Uceph software (Online Version 4.1.1, Sichuan University, China). All cephalometric data were assessed by the same operator and measured using the software to minimize measurement errors. The first cephalometric analysis (Table 1) revealed a very severe skeletal Class II pattern (ANB: 12.5°) with mandibular retrusion (sella-nasion-B point angle (SNB), 72.5°; sella-nasion-D point angle (SND), 68.5°; and SL, 27.0 mm). The mandibular incisors were within normal limits (Frankfort mandibular incisor angle (FMIA)), 60°; incisor mandibular plane angle (IMPA), 90°; and L1–NB, 6.0 mm). The upper and lower lips were protrusive (upper lip– and lower lip–E-line distances were −1.0 mm and 6.0 mm, respectively). The panoramic radiograph showed that the maxillary right and left third molars, seven first premolars, and one mandibular lateral incisor were missing. The maxillary and mandibular right second molars exhibited locked occlusion, and the mandibular right and left third molars presented horizontal impaction (Figure 2).

Table 1.

Pretreatment cephalometric measurements.

Cephalometric skeletal angles	Normal value	Pretreatment value
SNA (°)	82.8 ± 4.0	85
SNB (°)	80.1 ± 3.9	72.5
ANB (°)	2.7 ± 2.0	12.5
SND (°)	77.3 ± 3.8	68.5
U1–NA (mm)	5.1 ± 2.4	−1
U1–NA (°)	22.8 ± 5.7	−1.5
L1–NB (mm)	6.7 ± 2.1	6
L1–NB (°)	30.3 ± 5.8	23.9
U1–L1 (°)	124.2 ± 8.2	147
GoGn–SN (°)	32.5 ± 5.2	37.8
SE (mm)	20.2 ± 2.6	20
SL (mm)	52.1 ± 5.4	27
FMA (°)	31.3 ± 5.0	30
FMIA (°)	54.9 ± 6.1	60
IMPA (°)	93.9 ± 6.2	90

FMA: Frankfort mandibular plane angle; FMIA: Frankfort mandibular incisor angle; IMPA: incisor mandibular plane angle; SNA: sella-nasion-A point angle; ANB: A point-nasion-B point angle; SND: sella-nasion-D point angle; SNB: sella-nasion-B point angle.

Figure 2.

Pretreatment lateral radiograph and fenestration of the anterior teeth.

Timeline

The patient’s treatment began in 2017 and was completed by 2021. The follow-up duration was 1 year.

Diagnostic assessment

The patient was diagnosed with skeletal Class II relationship and dental bimaxillary protrusion; severe deep overjet and overbite; high angle; gummy smile; mandibular retrusion; locked occlusion; tooth midline inconsistency; missing maxillary right and left third molars, seven first premolars, and one mandibular lateral incisor; and horizontally impacted mandibular right and left third molars.

Therapeutic intervention

The following treatment goals were established after analyzing and summarizing the above data:

At presentation, teeth A45B45C45D25 had been extracted, the single position of the first premolar was maintained in each area, and implant restoration was performed in the prosthodontics department. The third molars were extracted.

Maxillary and mandibular dentitions were aligned, and locked occlusion was corrected. The lower jaw was then guided forward to improve the patient’s profile. Two implants were placed on each side of the maxilla. The torquing auxiliary arch was used to treat the anterior tooth bone fenestration.

The overbite and overjet of the anterior teeth were finally improved, and a neutral relationship between the molar and canine teeth on both sides was maintained.

A retainer was used to ensure the stability of the occlusion.

The patient was transferred to the Department of Prosthodontics for implant treatment.

The patient preferred space closure rather than implantation of missing teeth. However, considering the condition of her anterior teeth and facial profile, she was eventually advised to maintain the missing space and implant the missing teeth.

During orthodontic treatment (July 2017), the patient was transferred to the oral surgery department for the extraction of two of her third molars. McLaughlin-Bennett-Trevisi (MBT) prescription brackets (3 M Victory Series) were bonded to the maxillary and mandibular dentition, including the second molars, and superelastic nickel–titanium alloy archwires (0.012, 0.016, 0.016 in × 0.022) were used for initial aligning and leveling. Finally, arches were leveled with 0.019 in × 0.025 in stainless steel wires. Six months later, the locked occlusion of the right maxillary and mandibular second molars was corrected. Space for the restoration of the four first premolars was reserved during the above-mentioned treatment (Figure 3).

Figure 3.

Facial and intraoral photographs and radiographs at 8 months before the use of the self-made four-curvature torquing auxiliary arch.

Given that the anterior teeth were severely upright, the self-made four-curvature torquing auxiliary arch was placed in the anterior tooth area in the eighth month of treatment (September 2018). This device was made using Australian arch wire with a diameter of 0.457 mm (The Fordrough, HayMills, Birmingham, B25 8DW, the UK). When in use, the formed base of the auxiliary arch was bent in a circumferential direction pointing to the curving process at an angle of approximately 150°. The four spatulate curving processes were inclined to the palatal side and pressed at an angle of approximately 30°. Two hooks were bent in the distal position of the two sides of the maxillary canine and hung on the main arch wire for auxiliary arch retention (Figure 4). Three-dimensional finite element study revealed that the force applied by the auxiliary arch was 0.5 N each time.¹³ A three-dimensional finite element study was conducted, in which the force was gradually increased by 0.5 N within the safe stress range of the periodontal ligament such that approximately 0.5 N of force was added every month. In May 2019, 2 microimplants (Rrand, Ormco; diameter: 1.4 mm; length: 8 mm) were separately placed between the second and first molars in each quadrant. The detailed procedure is as follows:

Figure 4.

The self-made four-curvature torquing auxiliary arch.

After disinfecting the mucosa of the implant area and performing local infiltration anesthesia, the implant was vertically inserted at the implant site once adequate anesthesia was achieved.

Once the bone cortex was penetrated, the angle was gradually changed to 45°, and implantation was performed.

One month later, en masse retraction began with 3.5 oz (1/4) orthodontic rubber bands from short hooks to microimplants, which were fixed on the wire between the canine and lateral incisor in each quadrant.

At the same time, the position of the four premolars was maintained using springs. A spring was used to maintain the gap in the missing tooth area.

Bilateral Class II elastics orthodontic rubber bands (2.5 oz, 3/8) were simultaneously employed to continue the advancement of the mandible and help establish the Class I molar relationship (Figure 5).

Figure 5.

Facial and intraoral photographs and radiographs at 11 months, after 3 months of using the self-made four-curvature torquing auxiliary arch.

The torque of the anterior teeth was corrected in January 2020, and the occlusion of the anterior teeth gradually normalized. The occlusal relationship of the bilateral molars was identified as correction Class I. The positions of the four premolars were maintained well over another 5 months of treatment. The torquing auxiliary was continued in the following finishing stage because the maxillary incisors remained upright. In the later stage, fine adjustment was made to establish a neutral molar relationship and attempt to fit the middle line (Figure 6).

Figure 6.

Facial and intraoral photographs and radiographs at 17 months, after 9 months using the self-made four-curvature torquing auxiliary arch.

The total orthodontic treatment duration was 27 months (August 2021). A Hawley retainer was used for 24 h in the first 6 months after the removal of metal fixed appliances, and two right premolars were implanted. Given the patient’s financial constraints, two left premolars were not implanted. The patient then used a Hawley retainer at night for approximately 2 years. During the retention stage, the patient regularly visited the clinic once every 6 months (Figure 7).

Figure 7.

Facial and intraoral photographs at 27 months.

Follow-up and outcomes

The active orthodontic treatment duration was 48 months. The bilateral molars showed Class I relationships, and the overjet decreased from 3.0 to 1.2 mm. The occlusal relationship between the two sides was good. The patient was highly satisfied with her post-treatment lateral profile. She appeared as if she had undergone orthognathic surgery. Her deep overbite decreased from approximately 6 to 2.5 mm. The locked occlusion of the right maxillary and mandibular second molars had been corrected.

During the second orthodontic treatment, the anterior teeth and root exposure issues were resolved using a self-made four-curvature torquing auxiliary arch and microimplants while avoiding excessive adduction of the extraction space. The incisor torque and roots varied considerably during the treatment (Table 2). The incisor torque changed at the initial stage of tooth alignment and leveling (U1–NA, −1.0 to 0.2 mm; U1–NA, −1.5°; L1–NB, 6.0 to 6.36 mm; L1–NB, 23.9° to 22.0°). After the use of microimplants and the four-curvature torquing auxiliary arch in the following treatment, the following four measurements changed significantly: (a) U1–NA: 0.2 to −1.0 mm; (b) U1–NA: −1.5° to 11°; (c) L1–NB: 6.0 to 7.2 mm; and (d) L1–NB: 22° to 29.0°. The anterior teeth were severely upright (U1–NA, −1.0 mm and U1–NA, −1.5°). After 8 months of treatment using the self-made four-curvature torquing auxiliary arch, the upright anterior teeth had greatly improved (U1–NA, −1.0 mm and U1–NA −1.5° to 11°), and no closing stage was observed even in the extraction space. Cephalometry revealed that anchorage was well controlled in all directions, and no forward movement of the lower jaw molar was detected. The position of the restorative gap was guaranteed. Only the torque of the anterior teeth root had changed, and no labial inclination of the cusp was observed. Moreover, the other teeth had good axial direction and good occlusal contact (Figure 8).

Table 2.

Cephalometric measurements.

Cephalometric skeletal angles	Normal value	July 2017	September 2018	May 2019	January 2020	August 2021
SNA (°)	82.8 ± 4.0	85	85.5	84	84	83.95
SNB (°)	80.1 ± 3.9	72.5	75	74.5	74	76.64
ANB (°)	2.7 ± 2.0	12.5	10.5	9.5	10	7.32
SND (°)	77.3 ± 3.8	68.5	72	72	71	72.4
U1–NA (mm)	5.1 ± 2.4	−1	0.2	−1	−1	1.39
U1–NA (°)	22.8 ± 5.7	−1.5	1.5	6.5	11	14.32
L1–NB (mm)	6.7 ± 2.1	6	6.36	7.5	7.2	6.6
L1–NB (°)	30.3 ± 5.8	23.9	22	29	29	31.19
U1–L1 (°)	124.2 ± 8.2	147	147	135	131	127.17
GoGn–SN (°)	32.5 ± 5.2	37.8	37.5	38	38	38.11
SE (mm)	20.2 ± 2.6	20	20	19	19	15.22
SL (mm)	52.1 ± 5.4	27	32.7	32.5	32.7	26.17
FMA (°)	31.3 ± 5.0	30	33	32.5	32.5	32.7
FMIA (°)	54.9 ± 6.1	60	62	55	55	53
IMPA (°)	93.9 ± 6.2	90	85	92.5	92.5	94.3

FMA: Frankfort mandibular plane angle; FMIA: Frankfort mandibular incisor angle; IMPA: incisor mandibular plane angle; ANB: A point-nasion-B point angle; SND: sella-nasion-D point angle; SNB: sella-nasion-B point angle; SNA: sella-nasion-A point angle.

Figure 8.

Comparison of periapical radiographs before and after the use of the self-made four-curvature torquing auxiliary arch.

The Class II skeletal relationship had improved, and ANB° decreased from the initial value of 12.5° to 10.0° after treatment. The changes in the ANB° and SNB° fluctuated throughout the treatment period. The ANB° remarkably decreased from 12.5° to 10.5° at the beginning stage of leveling and substantially decreased from 10.5° to 9.5° after treatment with the four-curvature torquing auxiliary arch and microimplants. It then stabilized at approximately 10.0°. The SNB° initially increased from 72.5° to 75°; subsequently, it decreased and stabilized at approximately 74°. These results could be attributable to the fact that the four-curvature torquing auxiliary arch did not apply force. The four-curvature torquing auxiliary arch and microimplants contributed to the skeletal Class II correlation by approximately 3°. The additional change of 0.5° may be attributed to the lack of force applied by the self-made curvature torquing auxiliary arch during en masse retraction and root control. The mandibular plane angle had changed slightly, as shown by the GoGn–SN and Frankfort mandibular plane angle (FMA) measurements recorded throughout the treatment period. The incisor torque and root position changed markedly during the treatment period, with all parameters gradually normalizing or approaching normal values from the initially abnormal values. SNB, SND, U1–NA (°), L1–NB (°), and U-NA (mm) improved from the initially deficient values at treatment initiation to normal values during treatment. ANB and U1-L1 angles increased markedly at the beginning of treatment but normalized by the time of treatment completion.

CBCT was performed as follows:

Selection of the reference point. The doctor first selected a clear reference point on the tooth crown (such as the incisal edge or occlusal surface) on the three-dimensional image as the starting point for the measurement.

Location of the apical foramen. Subsequently, the apical foramen in the root apex area was identified and marked as the endpoint. The software supports multiplanar reconstruction, allowing simultaneous viewing of axial, coronal, and sagittal images to facilitate precise location of the apical foramen.

Automatic calculation of distance. After two points were selected, the software automatically calculated and displayed the three-dimensional straight-line distance between the two points. This measurement value was the distance from the tooth crown to the apical foramen. The above process can be combined with bone density color mapping and volume rendering to enhance the visibility and accuracy of the anatomical structure.¹⁴

Method error. The CBCT images were redirected. The long axis of each tooth was then determined as previously described. The distance for lateral incisors was measured in the sagittal plane, whereas that for canines was measured in the coronal plane.

Periodontal assessment.¹⁵ The patient exhibited poor oral hygiene. No obvious gum recession was observed. The CBCT scan revealed no obvious absorption of the alveolar bone.

Before the treatment, the probing depth (PD) was ≤3 mm, with no bleeding on probing (BOP), and a plaque index (PLI) of 0. After treatment, the PD was ≤3 mm, there was no BOP, and the PLI was 0. Follow-up assessment revealed a PD ≤3 mm, no BOP, and a PLI of 0.

The most recent follow-up visit was conducted 24 months after treatment, and the patient’s clinical parameters were stable. At the follow-up visit, two premolars had already been implanted. Implant placement had not been performed on the left side because of the patient’s financial constraints (Figure 9).

Figure 9.

Comparison of facial photographs (2017, 2018, 2019, 2020, 2021).

Discussion

Orthodontic treatment of skeletal maxillary protrusion involves controlled lingual movement of the maxillary incisors to achieve normal axial tilt and effectively reduce protrusion.¹⁶ When the extraction space is closed, the anterior teeth should be upright on the base bone as much as possible for the establishment of a good occlusal relationship, achievement of functional aesthetics, and stable orthodontic treatment. The control of tooth torque is closely related to facial aesthetics, functionality, and treatment stability. In clinical practice, effective torque control can not only facilitate the formation of a gentle and smooth dental curve but also ensure normal occlusion, overbite, and overjet and effectively ensure the stability of orthodontic treatment.^17–19

Control of tooth position has been used as an objective reference standard since Andrews proposed the six criteria for natural normal occlusion and established the measurement standards of tooth position, including torque.²⁰ Thorough tooth torque adjustment is required to achieve satisfactory clinical orthodontic occlusion. Anterior teeth must be corrected after bone fenestration and fracture during treatment to avoid serious consequences.^21,22 Although the torque characteristics of various orthodontic square wires have been studied by scholars, most studies have been limited to the 0.46-mm bracket system. The force and expression of the torque are limited. In our patient, the maxillary incisors were severely upright (initial U1–NA values: −1.5° to 11°) during the middle of treatment. Upright maxillary incisors would result in root protrusion, which negatively affects upper lip retraction. We used our self-made four-curvature torquing auxiliary arch for treatment to address the lingual inclination of the anterior teeth.

Ross et al.²³ reported that relative to the occlusal plane, the lip incline of normal maxillary central incisors with a high angular surface had decreased, whereas that of maxillary central incisors with a low angular surface had increased and was compensatory. In patients with highly angular surfaces, mandibular central incisors are compensatorily upright and their lip inclination is low relative to the mandibular plane. By contrast, in patients with low angular surfaces, the lip inclination of their mandibular central incisors is compensatory, and the torque is increased. Tweed was employed to analyze normal occlusion in children of White ethnicity in the United States and showed that good curative effects could be achieved for different malocclusions when the FMA was 25°, IMPA was 90°, and FMIA was 65°. At the same time, an FMIA of 65° is an important condition for establishing a good profile. The FMA is generally difficult to change through orthodontic treatment. However, an FMIA of 65° can be achieved by changing the position of the mandibular central incisors and lip incline, which represents a common clinical objective in orthodontics.

Patient’s perspective

After orthodontic treatment, the patient was satisfied with her soft tissue profile as well as the safety and stability of incisor occlusion. Good anterior torque not only exerts a remarkable effect on smile appearance but is also conducive to the establishment of anterior overbite, overbite relationship, force conduction, periodontal health, temporomandibular joint health, posterior cusp–fossa occlusion relationship, and orthodontic treatment stability. This patient reported a high level of satisfaction with her lateral profile without the need for surgery to correct her severe skeletal bimaxillary protrusion.²⁴

Footnotes

Acknowledgments

We would like to express our sincere gratitude to Professor Xiu-Jie Wen and Liu Rui for their contributions to this article.

Author contributions

Ping-Zhu Yang contributed to conceptualization, formal analysis, investigation, and original draft preparation; Xiu-Jie Wen contributed to manuscript review, editing, and data curation; Rui Liu contributed to supervision and project administration.

Data availability statement

All data generated or analyzed during this study are included in this manuscript.

Declaration of conflicting interests

All authors declare no conflicts of interest.

Funding

The authors declare that no funds, grants, or other financial support were received for the conduct of this study or preparation of this manuscript.

Statement of informed consent

The patient provided informed assent and signed consent for the publication of this case report.

Summary and conclusions

In modern orthodontic treatment, adding torque to the anterior tooth segment of the main arch wire can further strengthen torque control. However, this method is limited and cannot improve the torque problem caused by teeth with severe orthodontic issues and resolve the issue of bone fenestration. Our case report indicates that the combination of microimplants and our self-made four-curvature torquing auxiliary arch is a new feasible treatment option for patients in whom roots were exposed outside the cortical bone either during or after treatment. However, while using the auxiliary arch, force must be applied within the safe range to achieve effective torque transmission.

ORCID iD

Ping-Zhu Yang

References

Alfallaj

Pre-prosthetic orthodontics. Saudi Dent J 2019; 32: 7–14.

Chanmanee

Charoemratrote

Maxillary anterior gingiva and dentoalveolar changes after en-masse retraction between thick and thin gingival biotypes. Am J Orthod Dentofacial Orthop 2022; 161: 838–848.

Liu

Wang

, et al. Biomechanical effects of a new crimpable gate spring combined with conventional rectangular archwires for torque adjustment of individual anterior teeth. J Orofac Orthop 2025; 86: 424–434.

Chaudhary

Sharma

Comparative evaluation of torque prescription of commercially available 018Roth and 022MBT PEA brands in maxillary anterior teeth. Med J Armed Forces India 2019; 75: 415–423.

Barros

Faria

Jaramillo Cevallos

, et al. Torqued and conventional cantilever for uprighting mesially impacted molars: a 3-dimensional finite element analysis. Am J Orthod Dentofacial Orthop 2022; 162: e203–e215.

D’Oliveira

Monill-González

Valle-Cañada

, et al. Is there really a relationship between maxillary and mandibular incisor inclination and the amount of surrounding cortical alveolar bone? a systematic review. BMC Oral Health 2025; 25: 1397.

Khalil

Alrehaili

Hakami

, et al. Choosing the right extraction pattern: first premolars vs. second premolars. Cureus 2025; 17: e88171.

Mundhada

Jadhav

Reche

A review on orthodontic brackets and their application in clinical orthodontics. Cureus 2023; 15: e46615.

Al-Bozaie

Baba

Hajeer

MY.

An evaluation of the rate and type of orthodontic tooth movement when injecting platelet-rich plasma during mini-implant-based segmented en-masse retraction of upper anterior teeth. Cureus 2024; 16: e62368.

10.

Wądołowska

Lis

Kawala

, et al. Methods of orthodontic microimplant surface modifications providing antibacterial properties: a systematic review. Materials (Basel) 2025; 18: 3575.

11.

Gagnier

Kienle

Altman

; CARE Group*et al. The CARE guidelines: consensus-based clinical case reporting guideline development. Glob Adv Health Med 2013; 2: 38–43.

12.

Kara-Boulad

Burhan

Hajeer

, et al. CBCT-based assessment of apical root resorption and alveolar bone height following orthodontic treatment of Class I moderate crowding with labial vs. lingual fixed appliances in young adults: a randomized controlled trial. Int Orthod 2025; 23: 100968.

13.

Yang

Bai

Zhang

, et al. Efficacy of a four-curvature auxiliary arch at preventing maxillary central incisor linguoclination during orthodontic treatment: a finite element analysis. BMC Oral Health 2023; 23: 144.

14.

Ba-Hattab

Tamr

Shaweesh

, et al. Three-dimensional evaluation of pulp chamber volume and dimensions across skeletal and dental malocclusions using CBCT: a retrospective cross-sectional study. Clin Oral Investig 2025; 29: 516.

15.

Shaadouh

Hajeer

Alam

, et al. Effect of low‐intensity electrical stimulation on external apical root resorption and periodontal indices following en‐masse retraction of upper anterior teeth in young adults: a randomized controlled trial. Clin Exp Dent Res 2025; 11: e70188.

16.

Obeisi

Alanazi

Natto

, et al. Long-term stability and safety of orthognathic-orthodontic correction for skeletal anterior open bite: a systematic review and evidence appraisal. Cureus 2025; 17: e98816.

17.

Khursheed Alam

Younis Hajeer

Shqaidef

, et al. Impact of various aligner auxiliaries on orthodontic activity: a systematic review and network meta-analysis. Saudi Dent J 2024; 36: 199–207.

18.

Kheshfeh

Hajeer

Al Hinnawi

, et al. How effective are non-frictional techniques compared to sliding techniques in the retraction of upper anterior teeth when using buccal fixed-appliance therapy? A systematic review. J Clin Med 2023; 12: 6757.

19.

Raghav

Khera

Bhasin

Effect of micro-osteoperforations on rate of space closure by mini-implant supported maxillary anterior en-masse retraction: a randomized clinical trial. J Oral Biol Craniofac Res 2021; 11: 185–191.

20.

Park

JH.

Recovery of anterior torque loss and correction of deep bite occuring during orthodontic treatment with premolar extraction in class II patients. AJO-DO Clin Companion 2021; 1: 31–42.

21.

Yang

Zhang

, et al. Orthodontic treatment of a convex profile patient with deep overbite, retroclined maxillary incisors, and spacing via fixed appliances and mini-implants. AJO-DO Clin Companion 2022; 2: 283–293.

22.

Komaki

Hamanaka

Tominaga

, et al. Biomechanical features of tooth movement from a lingual appliance in comparison with a labial appliance during space closure in sliding mechanics. Am J Orthod Dentofacial Orthop 2022; 162: 307–317.

23.

Ross

Bennett

Trevisi

Long-term cephalometric changes after premolar extraction orthodontic treatment. The Angle Orthodontist 2018; 88: 492–498.

24.

Ghafari

JG.

Centennial inventory: the changing face of orthodontics. Am J Orthod Dentofacial Orthop 2015; 148: 732–739.