Case Report

Class III malocclusion and bilateral cross-bite in an adult patient treated

with miniscrew-assisted rapid palatal expander and aligners
Luca Lombardoa; Antonella Carluccib; Bortolo Giuliano Mainoc; Anna Colonnab; Emanuele
Paolettod; Giuseppe Sicilianie

ABSTRACT
This case report describes the use of a miniscrew-assisted rapid palatal expander and aligners to
correct bilateral cross-bite and crowding in an adult patient with a Class III skeletal pattern. A
digitally designed surgical guide was three-dimensionally printed and used to accurately insert four
miniscrews into the palate; these were employed to anchor a novel miniscrew-assisted rapid palatal
expander appliance without any dental anchorage. Cone-beam computed tomograms before and
after miniscrew-assisted rapid palatal expander treatment demonstrated the orthopedic expansion
of the maxilla without dental tipping. The patient was then fitted with aligners to correct crowding
and malocclusion. This case report demonstrates the successful treatment of an adult patient with a
narrow maxilla and bilateral cross-bite using a nonsurgical, conservative treatment. (Angle Orthod.
2018;88:649–664)
KEY WORDS: Rapid palatal expander; Aligners; Miniscrew

INTRODUCTION assisted rapid palatal expander (MARPE), which was

used to treat a 20-year-old patient with transverse
Nearly 30% of adult orthodontic patients present with
discrepancy for mandibular prognathism, obviating the
a transverse maxillary deficiency and posterior cross-
need for orthognathic surgery. Expansion was suc-
bite. For many years, surgically assisted rapid palatal
cessfully achieved with minimal damage to the teeth
expansion has been the treatment of choice to resolve and periodontium, and the authors concluded that
maxillary constriction in young adults, although several MARPE was an effective means of correcting trans-
authors have reported successful nonsurgical expan- verse deficits. Moreover, as the miniscrews are
sion in young and adult patients.1–5 However, Chang et anchored to the basal bone, the orthopedic force
al.6 described possible side effects in nonsurgical palatal exerted by the appliance results in pure skeletal
expansion that, in adult patients, may produce dentoal- movement while minimizing unwanted dental effects.8
veolar tipping with unfavorable periodontal effects. Based on the study by Lee et al., many authors have
In 2010, Lee et al.7 introduced an appliance secured recently developed novel skeletal expanders with the
to the palate by means of miniscrews, the miniscrew- aid of miniscrews, and new MARPE devices have been
used to correct maxillary constriction in patients of
a
Research Assistant, Postgraduate School of Orthodontics, various ages.9–11 In addition, other authors have
University of Ferrara, Ferrara, Italy. developed a hybrid palatal expander, introducing
b
Research Fellow, Postgraduate School of Orthodontics,
University of Ferrara, Ferrara, Italy. surgical guides (Miniscrew Assisted Palatal Appliance,
c
Visiting Professor, Postgraduate School of Orthodontics, MAPA system) for miniscrew insertion into the palate to
University of Ferrara, Ferrara, Italy. prevent damage to the anatomical structures.12,13
d
Orthodontic Technician, Lab Orthomodul, Thiene, Italy. Furthermore, to prevent undesirable tooth anchorage
e
Professor and Chairman, Postgraduate School of Orthodon-
effects at high risk of causing periodontal or root
tics, University of Ferrara, Ferrara, Italy.
Corresponding author: Luca Lombardo, Research Assistant, damage, a pure skeletal anchorage expander called
Postgraduate School of Orthodontics, University of Ferrara, the bone-anchored maxillary expander has been
Ferrara, Italy described.14
(e-mail: [email protected])
Accepted: February 2018. Submitted: November 2017. CASE REPORT
Published Online: May 1, 2018
Ó 2018 by The EH Angle Education and Research Foundation, This case report describes an adult female patient
Inc. with Class III malocclusion and bilateral cross-bite

DOI: 10.2319/111617-790.1 649 Angle Orthodontist, Vol 88, No 5, 2018

650 LOMBARDO, CARLUCCI, MAINO, COLONNA, PAOLETTO, SICILIANI

Figures 1–4. Initial photographs.

treated successfully with a pure skeletal anchorage The patient’s gum was delicate, friable, and translu-
maxillary expander and aligners. cent, demonstrating a thin gingival biotype. Recession
was visible at the maxillary and mandibular cuspids
Diagnosis and Etiology and bicuspids, and minor recession at the lower
incisors (Figure 1).
The patient, a 23-year-old woman, presented with a
Panoramic and laterolateral teleradiographs were
Class III malocclusion, transverse maxillary deficiency, taken by means of cone-beam computed tomography
and bilateral cross-bite (Figures 1a–e). Maxillary and
mandibular intermolar widths15 were 32 and 38 mm, Table 1. Cephalometric Assessment
respectively, and the patient displayed a flat profile and Measurement Pretreatment Posttreatment Change
skeletal asymmetry, featuring a deviation of the
SNA (8) 82 82 0
mandible toward the right (Figures 2–4). Cephalometric SNB (8) 81 80 1
analysis showed a Class III relationship (ANB 0, WITS ANB (8) 1 2 1
appraisal 5) with a long face (FMA 30.88). Maxillary WITS appraisal 5 5 0
SN MP (8) 40 41 1
incisors were proclined (maxillary central incisor to SN
FMA (8) 30.8 31.7 0.9
1178), and the mandibular incisors had a lingual Upper 1 to SN (8) 117 107 10
inclination (IMPA 828) as reported in Table 1. Overjet Upper 1 to APo (mm) 7.4 6.5 0.9
and overbite were reduced, and the lower dental Lower 1 o APo (mm) 5.3 4.4 0.8
Lower 1 to MP (8) 82 81 1
midline was deviated 3 mm to the right (Figures 5–9).

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Figures 5–9. Initial study models.

(CBCT; Figures 10–12), and an intraoral scan of the dimension, the MAPA system protocol was used to
dental arches was performed. Axial CBCT slices at the insert four miniscrews into the palate.12,13 This protocol
upper cuspids and bicuspids and at the furcation of first enabled bicortical anchorage guaranteeing greater
molars clearly showed a maxillary traverse deficiency resistance than that provided by orthopedic-loading
with bilateral cross-bite (Figures 13–15). A three- devices.16
dimensional skull model also revealed a diffuse paucity First, the Standard Triangulation Language (STL)
of buccal alveolar bone, in accordance with the clinical files obtained from intraoral scans of the patient were
finding of gingival recession (Figures 16–17). Coronal superimposed onto the CBCT Digital Imaging and
and sagittal cross-sections were used to measure Communications in Medicine (DICOM) files. The
palatal bone thickness (Figure 18). The patient thicknesses of the palate were measured, and the
reported a pronounced family history (both parents) ideal positions for four virtual miniscrews were
of Class III and maxillary constriction, indicating that identified (Figures 19–21). A three-dimensional tem-
the malocclusion was genetic in origin.
plate was then designed and three-dimensionally
printed (MAPA system).12,13 It featured precisely
Treatment Objectives
positioned cylindrical guide sleeves to enable the
The primary objective was orthopedic correction of correct placement of four miniscrews and rigorous
the posterior cross-bite by skeletal maxillary expansion control of the direction of insertion (two 11-mm and
without any dental compensation or worsening of the two 9-mm miniscrews, Ø 2 mm, Spider Screw,
periodontal situation. Additional objectives were to Regular plus, HdC, Thiene, Italy; Figures 22–25). A
achieve molar and canine Class I, correct the Polyvinyl Siloxane (PVS) impression of the upper arch
crowding, obtain ideal overjet (about 2.5 mm) and was then used to create the expansion device
overbite (about 2 mm), improve facial esthetics and (Figures 26–28). The treatment protocol included
incisor projection, and reduce black buccal corridors two activations per day17 until the mid-palatal suture
during smile. had opened and the constriction was corrected
(Figure 29). With 9 mm of appliance expansion, 7
Treatment Progress mm of expansion was obtained at the maxillary first
To avoid any adverse effects on the upper teeth, a molars, and 4 mm at the maxillary canines (Figure
bone-borne rapid palatal expander was selected. 30). Due to early contact between the upper and lower
Because the maxilla was narrow and thin in the vertical second molars, the open bite was increased and the

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Figures 10–12. Initial radiographs and cephalometric tracing.

device was left in situ for 2 months to stabilize the were delivered to the patient after composite grip
expansion. points had been attached to the buccal surfaces of
Postexpansion intraoral scans were taken and used teeth 13, 22, 23, 35, 44, and 45 and the lingual
to plan aligner treatment. In this phase, interproximal surfaces of teeth 12, 11, 21, from 31 to 42 (Figures 31–
reduction to teeth 13 and 22, 35 and 43 was performed 34), as prescribed by the digital set-up.
to gain space and facilitate the derotation move- Each aligner was worn for 7 days and, after this
ments.18–20 Then, 20 upper and lower individualized series, five upper and lower refinement aligners were
F22 aligners (Sweden & Martina, Due Carrare, Italy) prescribed so that an acceptable result could be

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RPE, SKELETAL ANCHORAGE, AND ALIGNERS 653

Figures 16–17. Three-dimensional skull model showing diffuse

paucity of buccal alveolar bone.

parison of the pre- and postoperative radiographs and

CBCT images reveal the maxillary expansion (Figures
43–47), which was also visible on dental casts (Figures
48–52). At the end of treatment, the patient displayed
Class I molar and canine relationships (due to an
increased positive tip, a slight edge-to-edge tendency
at the level of the canine was detectable). Cephalo-
metric data revealed an increase in the SNA (828) and
a reduction of the WITS index (Table 1). The data
Figures 13–15. Initial cone-beam computed tomography axial slices.
reported in Table 1 also show that the vertical position
of the maxilla was relatively unchanged, but that the
achieved. Aligner treatment, therefore, lasted slighly FMA was slightly increased (31.78), as demonstrated
longer than 6 months (Figures 35–41). At the end of by the overall superimpositions (Figures 53–55). The
this phase, the four miniscrews were removed from the upper incisors had been extruded and uprighted while
palate. After 2 weeks, the peri-implant tissues had the lower incisors remained unchanged (Table 1).
completely healed (Figure 42).
Measures of intermolar widths on the upper arches
before and after treatment showed an overall increase
Treatment Results
in width of 6 mm (at the level of the palatal cusps of the
After 10 months, the treatment was complete. The upper first molars; Table 2). Furthermore, all dental and
transverse constriction of the upper jaw had been skeletal objectives had been achieved and a satisfac-
corrected and the bilateral cross-bite resolved. Com- tory occlusal outcome was evident with no further

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654 LOMBARDO, CARLUCCI, MAINO, COLONNA, PAOLETTO, SICILIANI

Figure 18. Cone-beam computed tomography cross-sections showing palatal bone thickness.

increase in recession. Although there had been some the esthetics of the periodontal tissues. This multidis-
thinning of the buccal plates, there was still adequate ciplinary approach would have further enhanced the
coverage of the maxillary cuspids, bicuspids, and final outcome, providing results that could not be
molar roots even after expansion, as shown in the achieved by means of orthodontic treatment alone.
CBCT slices (Figures 56–58). Unfortunately, however, the patient refused surgery.
The face appeared more symmetric, the patient’s
profile had been maintained, and the overall esthetics DISCUSSION
had been improved. The patient displayed a nice,
There is a strong consensus in the literature as to the
broad smile, with improved incisor exposure and no
efficacy of rapid maxillary expansion in growing
buccal corridors. The patient was instructed to wear the
patients. However, in about 50% of cases, the reported
last pair of aligners for retention due to the elastic
expansion occurred at the mid-palatal suture, whereas
propriety of the thermoplastic material,21 and slight
in the remaining 50% of cases it was brought about by
restoration of tooth 22 was performed to achieve
displacement of the dentoalveolar complex.4 Age is
optimal anterior tooth proportions.22 Upon completion
considered a primary factor in the success of palatal
of orthodontic treatment, the patient was offered
expansion, and this is based on the idea that it rapidly
several periodontal surgery interventions to improve
Table 2. Skeletal Effects of Bone-Borne Rapid Maxillary Expander
Interdental Widthsa
Pretreatment Posttreatment Difference
U6 diameter (palatal 32 mm 38 mm 6 mm
crown)
U6 diameter (apex) 32.4 mm 38.1 mm 5.7 mm
U5 diameter (palatal 28.2 mm 33.6 mm 5.4 mm
crown)
U5 diameter (apex) 31.4 mm 37.4 mm 6 mm
U3 diameter (palatal 31 mm 34.4 mm 3.4 mm
crown)
Figure 19. Cross-section of the maxilla and virtual position of the a
U5: Upper second premolar; U6: Upper first molar; U3: Upper
miniscrews. canine.

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RPE, SKELETAL ANCHORAGE, AND ALIGNERS 655

Figures 20–21. Digital Imaging and Communications in Medicine

(DICOM) and Standard Triangulation Language (STL) file superim-
position of intraoral patient maxilla.

becomes inefficient after the early teens.23–25 In adults,

surgery had long been considered the only option for
orthopedic transverse correction. Nevertheless, many
authors have reported cases of rapid maxillary
expansion in adult patients based on the assumption
that the correction of maxillary constriction results in a
displacement of the alveolar process associated with
buccal displacement of the teeth.26 However, rapid
maxillary expansion in adults can produce unwanted
effects, including lateral tipping of the posterior
teeth,27,28 extrusion,29,30 buccal root resorption,31,32
alveolar bone bending,33 fenestration of the buccal
cortex,34,35 pain, and instability of the expansion.28,30,35
Carlson et al.17 and Mosleh et al.36 have reported
successful outcomes in patients treated with MARPE,
but these authors relied on an appliance anchored
partially to the teeth. Winsauer et al.,14 on the other
hand, reported one case of a 30-year-old patient
successfully treated with bone-borne anchorage with- Figures 22–24. Miniscrew Assisted Palatal Appliance (MAPA)
creation: three-dimensional–printed template for correct miniscrew
out unwanted dental effects.
placement.
To achieve true skeletal expansion, in this case a
pure skeletal anchorage expander was designed using

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656 LOMBARDO, CARLUCCI, MAINO, COLONNA, PAOLETTO, SICILIANI

Figure 25. Miniscrews inserted into the palate after surgical guide
removal.

a MAPA system to prevent any possible damage to the Figure 26. Polyvinyl Siloxane (PVS) impression showing the position
anatomical structures. Contrary to the belief that of the miniscrews.
nonsurgical palatal expansion is impossible in adult
patients, the posttreatment records of this adult patient
clearly show skeletal expansion, verified by measure- CONCLUSIONS
ments of CBCT images and models (Table 2). The  The successful resolution of this case shows the
posttreatment records of the patient show that the efficacy of a combined protocol involving miniscrew-
buccal tipping of the teeth was well controlled37,38 assisted rapid palatal expander and aligner treat-
(Figures 56–58; Table 3). The careful MARPE design ment to resolve Class III malocclusion with bilateral
and expansion protocol also resulted in a notable cross-bite in an adult patient, despite the wide-
improvement in the patient’s esthetics.39 Once ortho- spread belief that nonsurgical correction of such
pedic expansion of the upper jaw had been achieved, cases is impossible. This orthopedic approach
fully resolving the bilateral cross-bite, the patient was resulted in a better outcome than that previously
then fitted with aligners40; this confined the dental reported in the literature, even those pertaining to
movements to the required teeth. younger patients.
Such appliances as aligners can be extremely useful
in adult patients, especially in those with Class III or
vertical discrepancy issues, as they maintain dental
compensation without the need for other sources of
anchorage.41 Aligners also enable optimal oral hy-
giene, especially in adults, in whom there is a greater
risk of periodontal problems and a greater likelihood of
having a thin gingival biotype.42–44 A further advantage
of aligner treatment is the favorable esthetics, which
makes them better tolerated in patients, especially
adults.

Table 3. Skeletal Effects of Bone-Borne Rapid Maxillary Expander

Buccolingual Angulation
Pretreatment Posttreatment Difference
16 angulation 99.18 99.78 0.68
26 angulation 99.18 99.28 0.18
15 angulation 92.28 92.28 08
25 angulation 90.68 928 1.48
13 angulation 102.28 1008 2.28
23 angulation 104.28 1018 3.28
Figure 27. Model of the patient’s maxilla used for appliance creation.

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RPE, SKELETAL ANCHORAGE, AND ALIGNERS 657

Figure 30. Mid-palatal suture opening.

Figure 28. Miniscrew Assisted Palatal Appliance (MAPA) appliance

connected only to the four miniscrews.  Further studies are required to confirm the findings in
a larger sample of patients.

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Figures 43–44. Final photographs.

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Figures 45–47. Final radiographs and cephalometric tracing.

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Figures 48–52. Final models.

Figures 53–55. Superimpositions.

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Figures 56–58. Final cone-beam computed tomography axial slices

showing the final angulation of the dentition.

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