CASE REPORT

Correction of a skeletal Class II malocclusion

with severe crowding by a specially designed
rapid maxillary expander
Honghong Wang,a Jing Feng,b Peijun Lu,a and Gang Shenc
Shanghai, China

To correct an Angle Class II malocclusion or to create spaces in the maxillary arch by nonextraction treatment,
distal movement of the maxillary molars is required. Various modalities for distalizing the buccal segment have
been reported. Conventional extraoral appliances can be used to obtain maximum anchorage. However, many
patients reject headgear wear because of social and esthetic concerns, and the success of this treatment de-
pends on patient compliance. Intraoral appliances, such as repelling magnets, nickel-titanium coils, pendulum
appliance, Jones jig appliance, distal jet appliance, and modified Nance appliance, have been introduced to dis-
talize the molars with little or no patient cooperation. However, intraoral appliances can result in anchorage loss
of the anterior teeth and distal tipping of the maxillary molars. In this case report, we introduce a diversified rapid
maxillary expansion appliance that was custom designed and fabricated for the treatment of a growing girl with a
skeletal Class II malocclusion and severe crowding from a totally lingually positioned lateral incisor. The appli-
ance concomitantly expanded the maxilla transversely and retracted the buccal segment sagittally, distalizing
the maxillary molars to reach a Class I relationship and creating the spaces to displace the malpositioned lateral
incisor. The uniqueness of this special diversified rapid maxillary expansion appliance was highlighted by a se-
ries of reconstructions and modifications at different stages of the treatment to reinforce the anchorage. (Am J
Orthod Dentofacial Orthop 2015;147:242-51)

T
o correct an Angle Class II malocclusion or to
create spaces in the maxillary arch by nonextrac-
tion treatment, distalization of the maxillary mo-
lars is an alternative treatment approach. Various
modalities in distalizing the buccal segment have been
reported. Conventional extraoral appliances can be
used to obtain maximum anchorage. However, many
patients reject headgear wear because of social and
esthetic concerns, and the success of this treatment
depends on patient compliance.1 Beginning in the
1980s, intraoral appliances, such as repelling magnets,2
From the Department of Orthodontics, Shanghai Ninth People's Hospital,
Shanghai Jiao Tong University, Shanghai, China.
a
Postgraduate student.
b distalizing the maxillary molars to reach a Class I rela-
Assistant professor.
c
Chair.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Financial support from the National Natural Science Foundation of China, grant
no. 81271182.
Address correspondence to: Gang Shen, Department of Orthodontics, Shanghai
Ninth People's Hospital, Shanghai Jiao Tong University, Shanghai, China; e-mail,
orthoshengang@gmail.com.
Submitted, November 2013; revised and accepted, December 2013.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.12.032
242
nickel-titanium coils,3 the pendulum appliance,4,5 the
Jones jig appliance,6 the distal jet appliance,7 and the
modified Nance appliance,8 have been introduced to
distalize molars with little or no patient cooperation.
However, intraoral appliances can result in anchorage
loss of the anterior teeth and distal tipping of the maxil-
lary molars.9
In this case report, we introduce a diversified rapid
maxillary expander appliance (DRME) that was custom
designed and fabricated for the treatment of a girl
with a skeletal Class II malocclusion and severe crowding
from a totally lingually positioned lateral incisor. The
appliance concomitantly expanded the maxilla trans-
versely and retruded the buccal segment sagittally,
tionship and creating the spaces to align the remaining
maxillary dentition. The uniqueness of this special
DRME was highlighted by a series of reconstructions
and modifications at different stages of the therapy to
reinforce the anchorage.
DIAGNOSIS AND ETIOLOGY
The patient was an 11-year-old Chinese girl with a
chief complaint of crooked teeth. The initial clinical
Wang et al
Fig 1. Pretreatment extraoral and intraoral photographs showing an acceptable facial appearance, a
Class II molar relationship, and a lingually positioned maxillary right lateral incisor.
examination showed a slightly retrusive mandible with
an obtuse nasolabial angle and an increased labiomental
fold (Fig 1).
The intraoral examination and study casts exhibited
half-step Class II molar relationships on both sides.
The maxillary right lateral incisor was completely pala-
tally positioned (Fig 2). The maxillary midline was
4.0 mm off to the right of the facial midline, and the
mandibular midline was symmetrically correct. Crowd-
ing in the maxilla was severe as a result of an ectopically
placed right lateral incisor, whereas crowding in the
mandible was mild. The maxilla was constricted, and a
crossbite relationship was also noted in the left premolar
area. Study cast analysis showed an overbite of 3.0 mm
and an overjet of 2.5 mm.
The lateral cephalometric analysis showed a Class II
skeletal base (ANB, 5.7 ) with a protrusive maxilla
(SNA, 86.5 ), and an average mandibular plane angle
(FMA, 32.8 ) (Fig 3, Table). The U1-SN angle of 103.7
indicated a retroclined tendency of the maxillary incisors
American Journal of Orthodontics and Dentofacial Orthopedics
243
that might have caused an obtuse nasolabial angle. An
inspection of skeletal maturation by the cervical verte-
brae suggested considerable growth potential. The
panoramic radiograph showed that both maxillary
second molars were under development, and the tooth
buds of the maxillary third molars did not exist. Further-
more, no pathologic lesions, unusual root formations, or
deformities of the maxillary right central or lateral inci-
sors were identified with cone-beam computed tomog-
raphy (Fig 4).
TREATMENT OBJECTIVES
The treatment objectives for this patient were to (1)
relieve crowding by bringing the palatally positioned
lateral incisor into alignment, (2) correct the skeletal
Class II, (3) restore a satisfactory occlusion with Class I
molar and canine relationships, (4) correct the shifted
midline, (5) create ideal overbite and overjet, and (6)
improve the facial esthetics.
February 2015  Vol 147  Issue 2
244 Wang et al

Fig 2. Pretreatment study casts depicting the severity of crowding resulting from the malpositioned
maxillary right lateral incisor.

Fig 3. Pretreatment cephalogram and panoramic radiograph.

TREATMENT ALTERNATIVES
This preteen patient had adequate growth potential,
with an acceptable profile but with a retroclined maxil-
lary anterior dentition. A maxillary lateral incisor was
palatally positioned, but there were no signs of defects
in the overlapping areas between the adjacent dentition
(Fig 4). Furthermore, the maxillary second molars were
not erupted, indicating that the timing for molar distal-
ization might be an acceptable treatment modality. A
nonextraction treatment plan was therefore proposed.
The first step was orthopedic treatment with a specially
designed DRME (Fig 5). This appliance was designed
to expand the maxillary arch and distalize the maxillary
molars simultaneously to create spaces for crowding

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Wang et al 245

teeth. Seven months into the treatment, 5 mm of expan-

Table. Cephalometric data
sion and 4 mm of distalization were obtained (Fig 7). At
Norm Pretreatment Posttreatment Change the same time, the maxillary anterior teeth were also
SNA ( ) 82.0 6 3.5 86.5 84.3 2.2 aligned, the midline deviation was corrected, and a Class
SNB ( ) 77.7 6 3.2 80.8 81.5 0.7 I molar relationship on both sides was achieved.
SN-MP ( ) 32.9 6 5.2 31.7 32.7 1.0
The DRME was modified 7 months after the active
FMA ( ) 29.2 6 4.5 32.8 29.8 3.0
ANB ( ) 4.0 6 1.8 5.7 2.8 2.9 treatment followed by 2 months of retention (Fig 8,
U1-NA (mm) 4.3 6 2.7 2.6 6.3 3.7 A). The DRME was debonded and sent to the laboratory
U1-SN ( ) 103.4 6 5.5 103.7 107.3 3.6 for reconstruction: the casting crowns covering the sec-
L1-NB (mm) 4.0 6 1.8 5.3 8.0 2.7 ond premolars were removed so that we could proceed
IMPA ( ) 95.0 6 7.0 94.1 101.3 7.2
with distalization of the second premolars. The separate
Lower lip to 2.0 6 2.0 0.4 1.1 0.7
E-plane (mm) acrylic bases for the molars were fused together. The
Upper lip to 1.3 6 2.0 0.4 0.2 0.6 modified DRME was rebonded to the maxilla and served
E-plane (mm) as a strong anchorage similar to a Nance appliance. At
the same time, the second premolars were distalized,
relief and restoration of the molar relationship. The sec- and brackets were bonded in the mandibular arch.
ond step was orthodontic treatment with fixed appli- When the second premolars were distalized to touch
ances to improve the buccal interdigitation and the first molars, the DRME was debonded again for a
establish a proper incisal relationship. Microimplant second modification, which was conducted by removing
anchorage devices (MIAs) could be applied in the maxilla the anterior part of the DRME, so that it worked as a
to retract the frontal segment because the frontal transpalatal arch to consolidate the distalized first mo-
anchorage might be partially lost as a result of buccal lars (Fig 8, B).
segmental distalization. Sixteen months after the start of treatment, overjet
In the maxillary arch, by moving the buccal dentition increased. This might have been partly because of the
posteriorly, the maxillary left quadrant was to be distal- unavoidable partial loss of anchorage in the frontal
ized for midline correction, and crowding of the right segment against the buccal distalization, and partly
quadrant was to be relieved. In the mandibular arch, because of the eruptions of the maxillary second molars
mild crowding was to be relieved by expansion with that pushed the anterior teeth forward. To retract the
broad archwires, whereas the sagittal position of the maxillary front teeth backward, 2 MIAs (1.6 3 11 mm;
anterior teeth would remain to prevent further deep- Cibei, Ningbo, China) were placed between the maxillary
ening of the labiomental fold. second premolar and first molar to enhance the retrac-
Over the whole course of orthopedic treatment, the tion (Fig 9). Hawley retainers were prescribed upon
adaptive modifications to the DRME would remain a completion of active treatment.
constant endeavor to secure the frontal segment
anchorage against the buccal distalization and vice TREATMENT RESULTS
versa. Severe crowding that resulted from the correction of
the lingually positioned maxillary right lateral incisor
TREATMENT PROGRESS (Fig 10) was relieved. The dental midline deviation was
The treatment began with the placement of the corrected to become consistent with the facial midline.
DRME. The device consisted of 3 expansion screws and The posterior occlusal interdigitation was improved,
4 separate acrylic bases. The transverse expansion screw and Class I canine and molar relationships on both sides
was used to expand the maxillary arch, and 2 sagittal were also achieved. Ideal overbite and overjet relation-
expansion screws distalized the maxillary first molars. ships were restored (Fig 11).
The first and second premolars were covered with a cast- The cephalometric analysis and superimposition are
ing splint (Fig 5). The activation protocol for the 3 shown in Figures 12 and 13 and the Table. The overall
expansion screws was 1 turn every other day. After superimposition indicated that the patient's Class II skel-
3 months, interproximal spaces of 3 mm on both sides etal base changed to Class I. The regional superimposi-
were obtained between the second premolars and the tions demonstrated that in the maxilla, the incisors
first molars (Fig 6). Preadjusted 0.022-in brackets (Shi- were proclined about 3 , and the maxillary molars
nye, Hangzhou, China) were bonded to the maxillary were distalized 4 mm on both sides; in the mandible,
anterior teeth, and a 0.012-in nickel-titanium wire was the incisors were proclined about 7 , and the molars re-
engaged for prompt alignment of the maxillary front mained unchanged. Model analysis showed that the

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
246
Fig 4. Cone-beam computed tomography image identifying the position of the maxillary right lateral
incisor and its proximity to adjacent teeth.
Fig 5. The specially designed DRME featuring the diver-
sified transverse expansion and the sagittal distalizing
mechanism.
intercanine, interpremolar, and intermolar widths
increased by 1.2, 2.4, and 2.7 mm, respectively. The
maxillary dental length, which was measured as a linear
distance between the central incisors and the
second molars, increased by 4.3 mm. The patient's facial
esthetics were also improved.
DISCUSSION
Distalization of the maxillary molars is often attemp-
ted in the correction of a Class II malocclusion. It has been
demonstrated clearly that for molar distalization, intrao-
ral appliances are more effective and acceptable than ex-
traoral devices because they do not have an unesthetic
February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Wang et al
appearance10 or undesirable intermittent forces, and
they do not depend on patient cooperation.11 In addi-
tion, palatal-acting appliances consistently show less
tipping for all teeth than do buccal-acting appli-
ances.12-14 A possible reason for this is that the
moment arm of the force produced by palatally acting
appliances is smaller because its line of action is closer
to the center of resistance of the specific tooth.15
In this case, the specially designed DRME is a palatal-
acting appliance that facilitated displacement of the
maxillary teeth in 3 dimensions.
In the transverse plane, the width of the maxilla was
enlarged through the rapid maxillary expansion mecha-
nism. The spaces created by maxillary expansion were
mainly used to align the anterior teeth, especially the
maxillary right lateral incisor, which required consider-
able space to be labialized. In the transverse plane, rota-
tion of the maxillary first molars and premolars did not
occur, a favorable phenomenon possibly attributed to
the expanding force coupled with the distalizing one
against the concerned buccal teeth.
In the vertical plane, a previous study showed that
vertical movements were also present, and extrusions
of the incisors and premolars were observed with
noncompliance intramaxillary appliances.15 However,
in this patient, extrusion of the incisors, premolars,
and first molars was not evident. This might have been
due to the overall coverage of the casting frame to the
dentition that might have prevented any vertical move-
ment of individual teeth. The timing of the molar
Wang et al 247

Fig 6. Three months into treatment: effective expansion and distalized molars.

Fig 7. Seven months into treatment: further transverse expansion and molar distalization.

Fig 8. The adaptive reconstructions of the DRME: A, the casting coverages to the second premolars
were removed, and the posterior parts of the acrylic bases were fused to distalize the second premo-
lars; B, the anterior part of the DRME was removed, and the posterior one remained to retract the maxil-
lary labial segment.

distalization in this patient could also have been a factor.
According to Kinzinger et al,16 the side effects—eg,
tipping and extrusion—can be prevented or minimized
in molar distalization with a favorable developmental
status of the second molars, if their root formations
are far from total completion.
In the sagittal plane, it has been reported that
noncompliance intramaxillary molar distalization appli-
ances produce distal molar movement, which is a combi-
nation of distal crown movement and tipping, with a
concomitant and unavoidable loss of anchorage.15
Anchorage loss is observed through premolar mesial
movement and incisor mesial crown and tipping move-
ments. The pendulum appliance is one of the most
popular palatal appliances. Although distal movement
of the molars takes place remarkably, an adverse reaction
of mesialization of the premolars of 1 to 2.5 mm and
labial tipping of maxillary the incisors of 1.7 to 3.3
can occur.4,16-21 Therefore, on average, 55% to 80%
of the space obtained comes from distalization of the
molars and 20% to 45% from mesialization of the
premolars and labial tipping of the incisors. In this
patient, the anchorage against molar distalization was
increased as a result of the unique design of the
DRME, where the casting coverage of all premolars
and the acrylic base on an increased area of the palate
secured the anchorage rigidly. The anchorage control
was further indicated by cast measurement, which

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
248 Wang et al

Fig 9. MIAs were placed to enhance the anchorage for retraction of the maxillary labial segment.

Fig 10. Posttreatment extraoral and intraoral photographs showing an improved facial appearance,
and correction of the malpositioned maxillary right lateral incisor and the Class II molar relationship.

February 2015  Vol 147  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Wang et al 249

Fig 11. Posttreatment study casts.

Fig 12. Posttreatment cephalogram and panoramic radiograph.

showed distal movement of the molars of 4 mm and
distal tipping of 1.7 , and mesial movement of the
premolars of 0.4 mm and mesial tipping of 0.1 . Using
the Nance appliance, Antonarakis and Kiliaridis15 re-
ported molar distalization of 3.1 mm with 3.6 of distal
tipping, and premolar mesialization of 1.3 mm with 0.1
of mesial tipping. The maxillary incisors, on the other
hand, demonstrated 3.6 of labial tipping and 1.1 mm
of labial movement, indicating a certain degree of
anchorage loss in the labial segment. The proclination
of the maxillary incisors to some extent in this patient,
however, was favorable because it allowed not only for
the labial segment alignment, but also for the correction
of the originally retroclined maxillary incisors. Undeni-
ably, anchorage loss in this patient on the maxillary
anterior teeth occurred during distalization of the maxil-
lary first molars because the DRME was a tooth-and-tis-
sue–supported appliance rather than a bone-supported

American Journal of Orthodontics and Dentofacial Orthopedics February 2015  Vol 147  Issue 2
250 Wang et al

Fig 13. Posttreatment cephalometric superimpositions. The overall superimposition shows a skeletal
base change from Class II to Class I; the regional superimpositions show appropriate proclinations of
the maxillary and mandibular segments and correction of the molar relationship.

one. Several types of MIAs have been used in the palate
in conjunction with molar distalizing devices to provide
better anchorage, thus presumably reducing the unde-
sired side effects to the anterior dentition in the maxil-
lary arch.22-24 In this case, MIAs were placed at the
later stage in the posterior buccal alveolar bone as
reinforcement of anchorage against the retraction of
the maxillary labial segment.
Upon the successful molar distalization and creation
of spaces, it always remains a difficult and critical task to
distalize the premolars and then to retract the maxillary
labial segment without a substantial loss of anchorage
burdened on the already distalized molars. One common
clinical observation is that some posterior anchorage loss
is visible when retraction of the anterior teeth is carried
out in the second phase of treatment. In our patient, the
constant design modifications and laboratory recon-
structions of the DRME were implemented to reinforce
the anchorage sustainability from the distalized molars.
The first modification, where the casting coverage to the
second premolars was removed and the posterior parts of
the separated acrylic bases were merged (Fig 8, A), aimed
to better distalize the premolars at no cost of anchorage
loss in the first molars. The second modification, on the
other hand, where the whole anterior part of the DRME
was removed and the posterior part remained as a rigid
transpalatal arch (Fig 8, B), was designed to better
retract the maxillary labial segment without sacrificing
the anchorage in the buccal segment. The phasic modi-
fications and reconstructions of the DRME in this study
may become a new protocol for stabilization of the
already distalized molars and therefore secure the effi-
ciency of the premolar distalization and the subsequent
retraction of the maxillary front teeth.
To treat this patient without extractions, a significant
amount of maxillary molar distalization was critical. The
timing of the molar displacement, as mentioned earlier,
might have played a role. A favorable time to move mo-
lars distally appears to be in the mixed dentition before
the eruption of the second molars.25 Kinzinger et al16
suggested that the best time to start therapy with a
pendulum appliance is before the eruption of the
second molars in young patients. They also suggested
that if distalization of the first and second molars is
considered, enucleation of the third molar tooth buds
should be conducted simultaneously. Karlsson and

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Wang et al
Bondemark9 found that intraoral movement of the
maxillary first molars before eruption of the maxillary
second molars results in more effective molar movement
and less anchorage loss than after eruption of the
second molars. In this patient, a careful inspection of
the panoramic radiograph showed the developmental
status of the second molars with full crowns and the
initial formation of the roots (Fig 3), suggesting good
timing for molar distalization.
CONCLUSIONS
A specially designed intraoral orthopedic appliance,
the DRME, featuring transverse expansion and sagittal
distalization mechanisms, was used to treat a growing
patient diagnosed with a skeletal Class II base with severe
crowding. The concomitant and diversified orthopedic
forces contributed to creating spaces for relief of crowd-
ing in the labial segment and to achieving a Class I molar
relationship in the buccal segment. The adaptive recon-
structions of the DRME during different stages of the
treatment strengthened the anchorage of the distalized
molars to support the retraction of the premolars and
the labial segment.
ACKNOWLEDGMENT
We thank Dental Laboratory Ichban, Shanghai,
China, for fabrication and reconstructions of the ortho-
pedic appliance.
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