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Miniscrew-assisted nonsurgical palatal

expansion before orthognathic surgery for
a patient with severe mandibular prognathism
Kee-Joon Lee,a Young-Chel Park,b Joo-Young Park,c and Woo-Sang Hwangc
Seoul, Korea

A transverse maxillary deficiency in an adult is a challenging problem, especially when it is combined with a se-
vere anteroposterior jaw discrepancy. The demand for nonsurgical maxillary expansion might increase as pa-
tients and clinicians try to avoid a 2-stage surgical procedure—surgically assisted rapid palatal expansion
followed by orthognathic surgery—and detrimental periodontal effects and relapse. In this regard, a mini-
screw-assisted rapid palatal expansion was devised and used to treat a 20-year-old patient who had severe
transverse discrepancy and mandibular prognathism. Sufficient maxillary orthopedic expansion with minimal
tipping of the buccal segment was achieved preoperatively, and orthognathic surgery corrected the antero-
posterior discrepancy. The periodontal soundness and short-term stability of the maxillary expansion were
confirmed both clinically and radiologically. Effective incorporation of orthodontic miniscrews for transverse
correction might help eliminate the need for some surgical procedures in patients with complex craniofacial
discrepancies by securing the safety and stability of the treatment, assuming that the suture is still patent.
(Am J Orthod Dentofacial Orthop 2010;137:830-9)

ransverse maxillary deficiency is a relatively transverse dimension, described by Proffit et al2 as the
common clinical problem. It has been reported ‘‘transverse envelope of discrepancy.’’
that 9.4% of whole populations and nearly Maxillary constriction combined with severe
30% of adult orthodontic patients have a maxillary anteroposterior discrepancy is challenging, because it
transverse deficiency related to a posterior crossbite.1,2 usually requires 2 surgeries: SARPE followed by or-
Although rapid palatal expansion (RPE) has been thognathic surgery. Since many patients are reluctant
a reliable treatment modality in prepubertal patients, to undergo multiple surgical procedures, the demand
there have been controversies regarding nonsurgical for nonsurgical treatment might increase. However,
expansion in adults.3 Surgically assisted RPE (SARPE) even though nonsurgical palatal expansion is feasible,
has been the treatment of choice to resolve the high re- ample orthopedic expansion of the basal bone rather
sistance from the bony palate and the zygomatic but- than dentoalveolar tipping is essential to prevent detri-
tress,4 in contrast to reports of successful nonsurgical mental periodontal effects such as bony dehiscence
expansion in young adults.5,6 The difficulties in and to establish proper posterior occlusion.7 In this re-
dealing with the transverse discrepancy are associated gard, the appliance should be designed appropriately
with the limited range of tooth movement in the to maximize the skeletal effects.
Since conventional rapid palatal expanders that are
either tooth-borne (hyrax type) or tooth-and-tissue-
From the College of Dentistry, Yonsei University, Seoul, Korea. borne (Haas type) cause questionable effects on the
Assistant professor, Department of Orthodontics, Oral Science Research basal bone, a rigid element that delivers the expansion
Center, Institute of Craniofacial Deformity. force directly to the basal bone could be a solution.
Professor, Department of Orthodontics.
Resident, Department of Orthodontics. For this purpose, a miniscrew-assisted rapid palatal ex-
Supported by the 2006 research fund of the Institute of Craniofacial Deformity, pander (MARPE) was designed and used in an adult pa-
Yonsei University, Seoul, Korea. tient. This case report shows the treatment effects and
The authors report no commercial, property, or financial interest in the products
or companies described in this article. stability of the MARPE in a patient with severe maxil-
Reprint request to: Kee-Joon Lee, Department of Orthodontics, College of lary constriction and mandibular prognathism.
Dentistry, Yonsei University, 134 Shinchon-dong Seodaemun-gu, Seoul, Korea
120-752; e-mail,
Submitted, September 2007; revised and accepted, October 2007. DIAGNOSIS
Copyright ! 2010 by the American Association of Orthodontists. A 20-year-old man had severe mandibular progna-
doi:10.1016/j.ajodo.2007.10.065 thism. His past medical and dental histories were not
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 831
Volume 137, Number 6

Fig 1. Pretreatment facial photographs.

Fig 2. Pretreatment intraoral views showing severe transverse and anteroposterior jaw discrepancy.

remarkable. Initial intraoral and extraoral views shiwed compensation represented by U1 to SN of 117.0! and
a severe Class III malocclusion and a concave profile IMPA of 74.0! . The Wits appraisal was –20.5 mm. The
with a protrusive mandible and a retrusive maxilla SN-MP angle was relatively low (28.7! ) (Fig 4, Table).
(Fig 1). The severe bilateral buccal crossbite was asso- From the posteroanterior (PA) cephalometric analy-
ciated with relative constriction of the maxilla (Fig 2). sis, the maxillary basal bone width measurement was
The crossbite remained when the casts were reposi- 66.8 mm, and interantegonial notch width was 96.0
tioned to a Class I molar relationship, indicating an ab- mm, with resultant a maxillomandibular differential of
solute transverse deficiency.8 Maxillary and mandibular 29.2 mm (Table).
intermolar widths were 42.0 and 44.5 mm, respectively,
indicating that about 8 mm of maxillary expansion was
needed to establish proper buccal occlusion. Excessive TREATMENT OBJECTIVES
buccal tipping of the maxillary second molars was The treatment objectives were to (1) correct the
also noted. Incisor overbite was 14.5 mm, and overjet maxillary deficiency with sufficient maxillary expan-
was –7.0 mm (Fig 3). sion, (2) maintain sound periodontal support in the
The initial lateral cephalometric analysis showed maxillary arch throughout treatment, (3) establish an
a severe anteroposteior discrepancy with an ANB of esthetic profile with maxillomandibular orthognathic
–9.0! , SNA of 82.9! , and SNB of 91.9! , and dental surgery, and (4) establish proper buccal occlusion.
832 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2010

Fig 3. Pretreatment casts.

Because of the severe anteroposterior jaw relation-
ship, orthognathic surgery was inevitable. Accordingly,
several treatment options were suggested to deal with
the transverse discrepancies.
A SARPE before orthognathic surgery can be a reli-
able treatment option. Because of the severe maxillo-
mandibular discrepancy and the midface deficiency,
2-jaw surgery with a LeFort I osteotomy was indicated.
However, since SARPE and maxillary LeFort I osteot-
omy cannot be performed simultaneously, the patient
would require 2 stages of surgery. The possible
increases in surgical trauma and costs were concerns.
Maxillary segmental osteotomy for bilateral expan-
sion of the maxillary posterior segments with the man-
dibular surgery was also considered to correct both the
transverse and anteroposterior skeletal discrepancies in
1 surgery. However, lateral movements of the maxillary
segment have been shown to be considerably unstable.9
Extraction of the maxillary premolars can be a solu-
tion to reduce the relative discrepancy between the max-
illary and mandibular buccal segments, since it results
in a full-step Class II molar relationship. In this patient,
however, the transverse discrepancy at the molar width
was still there when the diagnostic casts were reposi-
tioned in a Class II relationship. Furthermore, incisor re-
Fig 4. Pretreatment x-rays (lateral cephalogram and traction would have prolonged the overall treatment.
panoramic x-ray). The increase in the negative overjet after maxillary
American Journal of Orthodontics and Dentofacial Orthopedics 0.25×42 10.5mm Lee et al 833
Volume 137, Number 6

Table. Cephalometric analysis before and after treatment firmed with intraoral radiographs and a PA cephalogram
Measurements Mean T0 T1 T2
(Figs 5-7). The miniscrews were maintained in place with
no notable positional change throughout the expansion
Lateral cephalogram phase. Expansion was terminated at 6 weeks, resulting
SNA (! ) 81 82.9 82.9 84.5 in an 8.3-mm increase in intermolar width. After active
SNB (! ) 78 91.9 92.0 83.0
ANB (! ) 3 –9.0 –9.1 1.5
expansion, the MARPE was maintained for 3 months
Wits (mm) –2 –20.5 –19.5 –4.5 to allow bone formation in the separated palatal suture.
SN-GoGn (! ) 35 28.7 29.7 37.7 The buccolingual molar inclination did not change after
U1 to SN (! ) 106 116.4 111.4 106.5 expansion and alignment (Fig 8). Transitional soft-
L1 to GoGn (! ) 94 74.0 80.0 80.1 tissue inflammation around the miniscrews in the poste-
Upper lip to E-line (mm) 1 –8.8 –8.3 –0.2
Lower lip to E-line (mm) 2 2.5 3.5 2.0
rior palate occurred during expansion but subsided after
PA cephalogram removal of the appliance. The maxillary second molar
Nasal cavity width (mm) NA 66.8 69.0 68.4 axis was corrected by applying elastic chains to the hooks
Maxillary basal bone width (mm) NA 34.0 36.5 36.0 attached to the molar bands.
T0, Initial; T1, before orthognathic surgery at 10 months; T2, final at The transverse increases were 2.4 mm in maxillary
16 months; NA, not applicable. basal bone width and 2.5 mm in nasal width, respec-
tively (Fig 7, Table).
Complete arch alignment and coordination were
performed for the orthognathic surgery. At 10 months,
incisor retraction would then necessitate excessive sur- a 2-jaw orthognathic surgery was performed involving
gical jaw movement that could be detrimental for the a maxillary LeFort I osteotomy for posterior impaction
stability of the surgery. and advancement and mandibular setback by 18.0 mm
Sufficient orthopedic expansion of the maxilla could with bilateral vertical ramus osteotomies (Fig 9).
eliminate the need for invasive surgery, if appropriately Occlusal settling was performed with vertical elas-
performed. However, in this patient, maximum skeletal tics. All brackets and bands were removed after 16
expansion without severe dental tipping and undesired months of treatment (Figs 10-12). Fixed retainers
periodontal side effects would be necessary, and the re- were attached on the maxillary and mandibular
sults would need to be stable after treatment. Special anterior teeth. A maxillary circumferential retainer
considerations were needed in designing the appliance was also used to secure the stability of the expanded
for nonsurgical expansion. maxillary arch.
There was no remarkable change in the clinical
TREATMENT PROGRESS crown heights at debonding compared with the initial
A MARPE was fabricated with some modification status. There was no notable gingival recession or
of the conventional RPE. An impression was made bony dehiscence in the posterior segments.
with the bands on the first premolars and first molars, Stable posterior occlusion was maintained for 18
and a conventional hyrax expander was constructed on months after debonding. Gingival recession or attach-
the cast. Four rigid connectors of stainless steel wire ment loss was not remarkable compared with the initial
with helical hooks were soldered on the base of hyrax status at 18 months after debonding (Fig 13, A-E). An
screw body. Two anterior hooks were positioned on axial computed tomogram was taken 12 months after
the rugae region, and the other 2 posterior hooks were debonding to view the periodontal status of the maxil-
placed on the parasagittal area (Fig 5, A). The hooks lary buccal segment. An axial section at 3 mm from
were adjusted for passive contact with the underlying the proximal cementoenamel junction showed sound
tissues. The MARPE was then placed and cemented periodontal surroundings in both the anterior and poste-
on the patient’s first premolars and molars. Orthodontic rior regions around the roots (Fig 13, F).
miniscrews (Orlus, Ortholution, Seoul, Korea) with
a 1.8-mm collar diameter and a 7-mm length were
placed in the center of the helical hooks under local in- TREATMENT RESULTS
filtration anesthesia. The wires were adjusted to main- Adequate nonsurgical bodily expansion of the max-
tain passive contact with the collar of the miniscrews. illary buccal segments was achieved. Desirable buccal
Nonsteroidal anti-inflammatory drugs were prescribed segment occlusion was established. The patient had
for pain control (Fig 5, B). sound and stable periodontal support after expansion
The hyrax screws were turned once a day starting the and completion of treatment. Balanced facial esthetics
next day. Separation of the midpalatal suture was con- resulted from the orthognathic surgery.
834 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2010

Fig 5. Fabrication and application of the MARPE: A, fabrication on the cast; B-D, placement of the
appliance and expansion procedure for 6 weeks; E, after consolidation and arch alignment at 10

Fig 6. Periapical views during maxillary expansion: A, before expansion; B, after 4 weeks of expan-
sion, with the upper diastema temporarily closed by resin buildup for esthetic reasons; C, after
consolidation and arch alignment at 6 months.

DISCUSSION confirmed by Knaup et al,16 who claimed that bony fu-

It has been a general perception that the predictabil- sion in the midpalatal suture was rare in subjects under
ity of orthopedic expansion is greatly reduced after 15 25 years. These findings substantiate anecdotal case re-
years of age, when SARPE may have to be used.3,10 ports in which conventional RPE produced successful
However, the validity of surgical or nonsurgical orthopedic effects.5
treatment should be reexamined in terms of feasibility, Nevertheless, a recent study showed that nonsurgi-
safety, and stability. cal expansion even in prepubertal patients leads to thin-
Early histologic studies showed that palatal suture ning of the buccal alveolar wall, which could develop
obliteration or synostosis begins when people are in a bony dehiscence.17 This effect was more evident in pa-
their thirties, and fusion of facial sutures is rare in older tients with tooth-borne expanders than tooth-and-tissue-
skulls, unlike the cranial sutures,11-15 which were borne expanders. This demonstrates the increased risks
of transverse expansion in postpubertal patients, in
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 835
Volume 137, Number 6

Fig 7. PA cephalograms: A, before expansion; B, after expansion; C, superimposition.

Fig 8. Changes in arch width and molar inclination: A, occlusal molds made of pattern resin (GC, To-
kyo, Japan) with wire for standardized measurement of the molar inclination; B-E, changes in molar
width and inclination before and after expansion.

whom stronger bone-borne anchorage is needed than sion has been difficult, mainly because of the problems
conventional expanders. Taken together, the maximum in designing a controlled experiment between age-
skeletal effect during and after expansion is a crucial matched groups.18,19 Berger et al20 stated that the
factor whether the expansion is surgical or nonsurgical. 1-year stability of SARPE in postpubertal subjects was
Although surgical osteotomies obviously allow not significantly different from that of nonsurgical ex-
maxillary skeletal expansion in adults, there have been pansion in prepubertal patients. Therefore, it can be
controversial opinions about the stability of the arch speculated that the treatment effects and the stability
width. Phillips et al9 reported considerable relapse after of nonsurgical expansion in adults are comparable
expansion with LeFort I and segmental osteotomy in 39 with those of SARPE, when the orthopedic expansion
patients. SARPE, therefore, was expected to show supe- is secured.
rior stability compared with segmental osteotomy, since Diagnostic criteria for surgical intervention have
it allows tissue adaptation during the expansion and been suggested in several ways. Handelman et al6 stated
subsequent consolidation period. However, an empirical that surgically assisted expansion should be used when
comparison between SARPE and nonsurgical expan- the required expansion of intermolar width exceeds 8
836 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2010

Fig 9. Treatment progress: A-C, after expansion at 6 weeks; D-F, before orthognathic surgery; G-I,
after orthognathic surgery.

Fig 10. Posttreatment facial photographs.

mm. Betts et al21 suggested the maxillomandibular MARPE is a simple modification of the conven-
width differential measured from the PA view, as a guide tional RPE appliance; the main difference is the incor-
for surgical expansion. According to those criteria, our poration of several miniscrews to ensure expansion of
patient would need 2-stage surgery. However, Bailey the underlying basal bone and maintain the separated
et al18 favored simultaneous segmental osteotomy and bones during the consolidation period. Posterior minis-
mandibular surgery over 2-stage surgery in long-face crews were placed close to the midpalatal suture to use
patients with narrow maxillae, due to surgical trauma, the bone thickness of the nasal crest.22,23 The treatment
morbidity, and cost. Thus, nonsurgical expansion may effects in this case can be defined as a combination of
be justified when it leads to treatment effects similar to skeletal and dentoalveolar expansion, since the
those of SARPE. appliance is tooth-and-bone-borne. The literature shows
American Journal of Orthodontics and Dentofacial Orthopedics Lee et al 837
Volume 137, Number 6

Fig 11. Posttreatment casts.

Fig 12. Posttreatment x-rays and cephalometric superimposition.

838 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2010

Fig 13. A-E, Follow-up intraoral photographs18 months after debonding; F, axial computed tomo-
gram showing the 3-mm apical level from the cementoenamel junction 12 months after debonding.

that considerable dentoalveolar expansion also occurred CONCLUSIONS

with SARPE,24 and the amount of expansion at the max- This case report introduced an RPE reinforced by
illary basal bone was not as much as the dentoalveolar orthodontic miniscrews (MARPE) positioned on the
expansion.25 A triangular expansion represented by palatal bone. It demonstrated the clinical effects in treat-
greater dentoalveolar expansion with less basal bone ex- ing a young adult with severe maxillary constriction and
pansion seems unavoidable because of the anatomic mandibular prognathism. To avoid multiple surgeries,
structure and the appliance design, whether the expan- nonsurgical maxillary expansion was performed with
sion is surgical or nonsurgical. the MARPE to achieve both skeletal and dentoalveolar
Some bone-borne maxillary expanders have been expansion for transverse correction. Subsequent orthog-
proposed in reports to facilitate the skeletal expansion nathic surgery corrected the mandibular prognathism
following lateral osteotomies.26-28 In contrast, our and vertical excess. The stability of the expansion and
tooth-and-bone-borne appliance required a simple proce- the periodontal status were favorable from the follow-
dure for miniscrew placement and definitely did not need up clinical and radiologic findings. This report proposes
an osteotomy, implying that an effective replacement of effective incorporation of orthodontic miniscrews for
SARPE with MARPE in young adults may be possible. transverse correction; this can eliminate the need for
In spite of our promising clinical results, the multiple surgeries in patients with complex craniofacial
MARPE appliance cannot be expected to force the sep- discrepancies and secure the safety and stability of the
aration of obliterated sutures in older adults. Therefore, transverse correction.
the indications for MARPE should be confined to young
adults from the late teens to the midtwenties, based on
the earlier studies.11,29 SARPE can still be a treatment REFERENCES
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