Advances in Oral and Maxillofacial Surgery 8 (2022) 100330

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Advances in Oral and Maxillofacial Surgery

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Case report

Use of miniscrew-assisted rapid palatal expansion before bimaxillary

orthognathic surgery: A case report
José Alfredo Facio Umaña *, José Arturo Óscar Martínez Aguilar, Pedro IV González Luna,
Roberto Beltrán del Río Parra
School of dentistry, Universidad Autónoma de Coahuila, Avenida Juárez y calle 17, Torreón, Coahuila, c.p. 27000, Mexico

A R T I C L E I N F O A B S T R A C T

Keywords: Class III malocclusions have been one of the major challenge to correct skeletal and dentofacial anomalies in
Class III Orthognatic surgery orthodontics, some class III patients have a maxillary hypoplasia resulting in an transverse discrepancy, the
Adult treatment golden standard for treat patients with severe class III skeletal malocclusions consists in a orthodontic therapy
Miniscrew-assisted rapid palatal expansion
and orthognathic surgery, currently Mini-screw assisted rapid palatal expansion with (MARPE) is an efficient
Presurgical rapid palatal expansion
procedure for correcting maxillary transverse deficiency even in adult patients. A 25-year class III skeletal female
patient with hyperdivergent growth anterior and posterior crossbite and laterognathia was treated, presurgical
miniscrew assisted rapid palatal expansion was chosen to correct the patient’s transverse deficiency, bimaxillary
surgery was conducted to treat the mandibular hyperplasia and facial asymmetry. Surgery consisted in 1-piece
Lefort to correct maxillary canting and BSSO to correct laterognathia. The treatment was complete in 18
months, CBCT images reveal the maxillary expansión, all dental and skeletal goals were achieved and the facial
result was evidente. MARPE can be use before bimaxillary orthognathic surgery to correct transverse maxillary
discrepancy and posterior cross-bite in adult patients, however different factors such as the severity of the
deficiency, age, and the conditions of the perimaxillary sutures must be taken.

1. Background improve maxillo-mandible relation and facial appearance [10].

Over the time class III malocclusions have been one of the major
challenge to correct skeletal and dentofacial anomalies in orthodontics,
for this reason a thorough diagnosis and treatment plan should be made
[1]. When patients have large discrepancies between the mandible and
the maxilla the most common procedure to correct dentofacial anoma­
lies in patients who are no longer growing or it is impossible to correct it
with orthodontic camouflage is the orthognathic surgery [2], in addition
some class III patients present maxillary hypoplasia and mandibular
hyperplasia with a low tongue posture, generating an completely
transverse discrepancy [3]. Mini-screw assisted rapid palatal expansion
(MARPE) is an efficient procedure for correcting a maxillary transverse
deficiency in young and adults patients [4–6]. MARPE not only produces
expansion of the maxillary bone, also causes a disjunction of all
circum-imaxillary sutures and the surrounding craniofacial structures
including nasal and zygomatic bone [7–9]. It has been described that
most efficient treatment to correct severe skeletal malocclusions consists
of a combination of orthodontic therapy and orthognathic surgery for
2. History
2.1. Assessment
A 25-year female patient complaining that she doesn’t like the way
she looks, the patient presented anterior crossbite and laterognathia.
The patient was being treated orthodontically due to crossbite 5 years
ago. Cephalometric analysis showed a Class III skeletal relationship with
hyperdivergent growth (Table 1). The patient presented an anterior
crossbite and a posterior crossbite from the upper left lateral incisor to
the first molar of the left side. She had a class III right and class I left
canine, a class III molar relationship on the right and a class I molar on
the left, with the upper midline displaced 2mm to the right and the lower
3 mm to the left relative to the facial midline (Fig. 1). CBCT transverse
analysis was performed by measuring the distance between the vestib­
ular crest of the upper and lower first molars, taking the pulp floor as a
reference, according to this analysis patient presented -2mm transverse

* Corresponding author.
E-mail address: jafu28@hotmail.com (J.A. Facio Umaña).

https://doi.org/10.1016/j.adoms.2022.100330
Received 14 July 2022; Accepted 18 July 2022
Available online 30 July 2022
2667-1476/© 2022 The Author(s). Published by Elsevier Ltd on behalf of British Association of Oral and Maxillofacial Surgeons. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
J.A. Facio Umaña et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100330

Table 1 screws (SMES, BioRAY) was required, using an 11 mm expander screw

Cephalometric assessment, pre-treatment (T0), pre-surgery (T1) and post- and 4 self-drilling mini-screws (1.8 mm in diameter and 10 mm in
treatment (T2). length). All mini-screws were placed parallel to each other, under local
Pre Tx (T0) Pre Surgery (T1) Post Tx (T2) anesthesia. To obtain bicortical retention on the palate, a 10 mm mini-
SNA 80.6 80.6 83.2
screws were used (Fig. 2). The device was welded to the ss bands and
SNB 84.4 84.4 81.1 glass ionomer was used for its cementation to the first upper molars
ANB − 3.8 − 3.8 2.1 (Fig. 3). According to Moon’s protocol, SMEs were activated by five
WITS − 19.5 mm − 19.5 mm − 11.5 mm turns a day for 2 weeks. After the diastema opened, only two turns were
SN-PP 9.5 8.6 10.6
given daily (0.25 mm per turn). The activations ends when the maxillary
Go-Gn SN 36.6◦ 37.5◦ 33.2◦
Mx1-SN 110◦ 107◦ 106◦ width was greater than the mandibular width (≥5 mm). SMEs remained
Md1-MP 94.2◦ 91.7◦ 91.7◦ unactivated for ≥10 months to maintain its retention. After 10 months
UL-E-line (mm) − 3.3 mm − 3.1 mm − 2.0 mm (1 month of expansion only and 9 months using orthodontic treatment),
LL-E-line (mm) 1.2 mm 1.8 mm − 1.0 mm the alignment of the teeth was satisfactorily completed (Fig. 4). Surgery
consisted in 1-piece Lefort to correct maxillary canting and BSSO to
discrepancy. correct laterognathia under general anesthesia, osteotomies were fixed
with mini-plates and screws (Fig. 5).

2.2. Treatment objectives

A presurgical mini-screw-assisted rapid palatal expansion was cho­
sen to treat a patient’s transverse discrepancy and minimize orthog­
nathic surgery procedure; after orthodontic treatment bimaxillary
surgery was chosen to treat the mandibular hyperplasia and facial
asymmetry. To correct maxillary canting and concavity of the facial
profile, 1-piece Lefort and Bilateral Sagittal Split Osteotomy (BSSO)
were planned.
2.3. Treatment progress
To perform this procedure, a skeletal maxillary expander device with
2.4. Treatment results
The treatment was complete in 18 months. The transverse maxillary
constriction was corrected and the unilateral cross-bite resolved with an
increase in width of 6 mm (Table 2). A comparison of CBCT images
before and after treatment reveals the maxillary expansion achieved
(Fig. 6). After treatment, the patient presents Class I molar and canine
left and right relationships (Fig. 7). Cephalometric values after treat­
ment shows an increase in the SNA (83.2◦ ), a decrease in the SNB
(81.1◦ ), and a decrease of the WITS index (− 11.5) (Table 1). Table 1 also
shows a counterclockwise rotation of the mandible (33.2◦ ) and the
vertical position of the maxilla was slightly increased (10.6◦ ). The upper

Fig. 1. Initial intraoral and extra-oral photographs.

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J.A. Facio Umaña et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100330

Fig. 2. Bicortical miniscrews.

and lower incisors had been retruded. All dental and skeletal goals were
achieved and the facial result was evidente (Fig. 8).
3. Discussion
Patients with skeletal Class III malocclusion showed greater buccal
inclinations of the upper posterior teeth and lingual inclinations of the
second molars in the mandibule [11], however, it has been demostrated
that nonsurgical palatal expansion is possible in adult patients with the
use of mini-screw-assisted rapid palatal expansion [12–14]. The main
objectives of orthodontic treatment before surgery are to decompensate
the teeth in the sagittal, vertical, and transverse planes [15]. We

Fig. 3. (A) Miniscrew-assisted Rapid Palatal Expansion appliance, (B) Postexpansion Opening of diastema after 21 days of activation.

Fig. 4. Alignment of the teeth before surgery.

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J.A. Facio Umaña et al.
Fig. 5. (A)Pre and (B)Post virtual surgical simulation of 1-piece Lefort to correct maxillary canting and BSSO to correct laterognathia orthognathic surgery.
Table 2
Transverse Analysis, Pre-treatment (T0) and Post-treatment (T1). The ideal
difference between the widths of the jaw should be 5 mm.
Initial (T0) Final (T1)
Maxillary width 58 64
Mandibular width 60 60
Difference -2mm 4mm
Fig. 6. (A)Initial, (B)Post expantion and (C)Post treatment CBCT coronal images.
resolved the maxillary transverse collapse and corrected the posterior
unilateral cross-bite with a nonsurgical orthopedic expansion with
MARPE before bimaxillary surgery, furthermore (1) minimize the un­
favorable effects such as vestibular inclination of the teeth and thinning
of the buccal bone plate demonstrated previously [16–18] and (2)
reduce the intraoperative surgery time and reduce the postoperative
complications such as posterior crossbite skeletal relapse that have been
reported [19]. Postoperative stability should always be considered since
surgical maxillary expansion with surgical descent of the maxilla are the
most unstable movement of all procedures in orthognathic surgery [20,
21]. The transverse increase of the maxilla in a single stage causes a
stretching of the palatine mucosa and the tension applies a force of
constriction to the operated maxilla which acts as a limitation for its
expansion and is a conditioning factor for its relapse [22,23]. In
maxillo-mandibular discrepancies greater than 6 or 7 mm, a first stage of
assisted maxillary expansion has been recommended to generate greater
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Advances in Oral and Maxillofacial Surgery 8 (2022) 100330
bone tissue as well as greater tissue in the palatine mucosa [24]. It has
been demostrated that 50% of the relapse in the first year after surgery
in transverse movements in a single stage correspond directly to loss of
bone tissue [25], while 60% in 2 stages corresponds to the dental po­
sition which can be managed when overcorrecting during the first stage
(assisted maxillary expansion) before orthognathic surgery, resulting in
greater long-term stability [23]. Yoon-Soo Ahn et al. evaluate the sta­
bility of bimaxillary surgery carried out with or without presurgical
rapid palatal expansion assisted with miniscrews in adult patients, they
suggest that nonsurgical expansion of the maxilla with MARPE can be
used to give stability in class III skeletal adult patients with maxillary
collapse [26] obtaining the same results as our clinical case. Diagnosis,
prognosis, and treatment of skeletal class III malocclusion have always
been a challenge for clinicians [27] the most common cause of unfa­
vorable results or post-surgical complications in patients undergoing
orthognathic surgery is the inadequate and inappropriate planning of
presurgical treatment [28], for this reason the diagnosis, orthodontics
surgical objectives, and treatment plan must be discussed and accepted
by both the orthodontist and the surgeon before starting treatment [29].
4. Conclusions
Mini-screw-assisted Rapid Palatal Expansion can be used before
bimaxillary orthognathic surgery to correct the transverse maxillary
discrepancy and posterior cross-bite in adult patients, however, several
J.A. Facio Umaña et al. Advances in Oral and Maxillofacial Surgery 8 (2022) 100330

Fig. 7. Post-treatment intraoral and extra-oral photographs after expantion, orthodontic treatment and orthognatic surgery.

Fig. 8. (A)Pre and (B)Post-treatment Cephalometric tracing.

factors must be considered, such as the severity of the deficiency, age,
and the conditions of the premaxillary sutures.
Acknowledgements
We thank Dr Javier De la Fuente Martínez for his contribution in the
digital surgical planning and Dr Jorge Mery Villalobos for his collabo­
ration in surgery of this case.
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