Nonsurgical treatment of severe vertical maxillary excess with short roots, thin bone, and a low maxillary sinus floor

Severe vertical maxillary excess (VME) is a skeletal abnormality that typically requires orthognathic surgery for correction. Nonsurgical orthodontic treatment has been a fascinating but challenging alternative, especially when adverse anatomic factors hamper or pose risks for intrusive tooth movement. Despite well-documented efficiency of temporary anchorage device (TAD)-aided nonsurgical treatment for VME, evidence is scarce regarding the treatment efficacy and safety for cases with adverse anatomic traits. In this case report, we present nonsurgical treatment of a patient with severe VME, maxillary protrusion, and retrognathism. Additional challenges included compromised periodontal health, low maxillary sinus floor, short roots with axes deviating from the center of basal bone, and thin labial cortical bone with partial deficiencies. With anchorage from a transpalatal arch (TPA) and TADs and elaborate biomechanical control strategies, significant maxillary full-arch intrusion and anterior retraction with adequate root torque control were achieved, resulting in counterclockwise mandibular rotation and notable profile improvement. One-year follow-up showed stable treatment results. This case provided evidence on how balance may be achieved between treatment efficacy and anatomical limitations using biomechanical control strategies.