CASE REPORT

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)

transverse dimension, described by Proffit et al2 as the

T
ransverse maxillary deficiency is a relatively
common clinical problem. It has been reported
that 9.4% of whole populations and nearly
30% of adult orthodontic patients have a maxillary
transverse deficiency related to a posterior crossbite.1,2
Although rapid palatal expansion (RPE) has been
a reliable treatment modality in prepubertal patients,
there have been controversies regarding nonsurgical
expansion in adults.3 Surgically assisted RPE (SARPE)
has been the treatment of choice to resolve the high re-
sistance from the bony palate and the zygomatic but-
tress,4 in contrast to reports of successful nonsurgical
expansion in young adults.5,6 The difficulties in
dealing with the transverse discrepancy are associated
with the limited range of tooth movement in the
From the College of Dentistry, Yonsei University, Seoul, Korea.
a
Assistant professor, Department of Orthodontics, Oral Science Research
Center, Institute of Craniofacial Deformity.
b
Professor, Department of Orthodontics.
c
Resident, Department of Orthodontics.
Supported by the 2006 research fund of the Institute of Craniofacial Deformity,
Yonsei University, Seoul, Korea.
The authors report no commercial, property, or financial interest in the products
or companies described in this article.
Reprint request to: Kee-Joon Lee, Department of Orthodontics, College of
Dentistry, Yonsei University, 134 Shinchon-dong Seodaemun-gu, Seoul, Korea
120-752; e-mail, orthojn@yuhs.ac.
Submitted, September 2007; revised and accepted, October 2007.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.10.065
830
‘‘transverse envelope of discrepancy.’’
Maxillary constriction combined with severe
anteroposterior discrepancy is challenging, because it
usually requires 2 surgeries: SARPE followed by or-
thognathic surgery. Since many patients are reluctant
to undergo multiple surgical procedures, the demand
for nonsurgical treatment might increase. However,
even though nonsurgical palatal expansion is feasible,
ample orthopedic expansion of the basal bone rather
than dentoalveolar tipping is essential to prevent detri-
mental periodontal effects such as bony dehiscence
and to establish proper posterior occlusion.7 In this re-
gard, the appliance should be designed appropriately
to maximize the skeletal effects.
Since conventional rapid palatal expanders that are
either tooth-borne (hyrax type) or tooth-and-tissue-
borne (Haas type) cause questionable effects on the
basal bone, a rigid element that delivers the expansion
force directly to the basal bone could be a solution.
For this purpose, a miniscrew-assisted rapid palatal ex-
pander (MARPE) was designed and used in an adult pa-
tient. This case report shows the treatment effects and
stability of the MARPE in a patient with severe maxil-
lary constriction and mandibular prognathism.
DIAGNOSIS
A 20-year-old man had severe mandibular progna-
thism. His past medical and dental histories were not
American Journal of Orthodontics and Dentofacial Orthopedics
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
a severe Class III malocclusion and a concave profile
with a protrusive mandible and a retrusive maxilla
(Fig 1). The severe bilateral buccal crossbite was asso-
ciated with relative constriction of the maxilla (Fig 2).
The crossbite remained when the casts were reposi-
tioned to a Class I molar relationship, indicating an ab-
solute transverse deficiency.8 Maxillary and mandibular
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
buccal tipping of the maxillary second molars was
also noted. Incisor overbite was 14.5 mm, and overjet
was –7.0 mm (Fig 3).
The initial lateral cephalometric analysis showed
a severe anteroposteior discrepancy with an ANB of
–9.0 , SNA of 82.9 , and SNB of 91.9 , and dental
Lee et al 831
compensation represented by U1 to SN of 117.0 and
IMPA of 74.0 . The Wits appraisal was –20.5 mm. The
SN-MP angle was relatively low (28.7 ) (Fig 4, Table).
From the posteroanterior (PA) cephalometric analy-
sis, the maxillary basal bone width measurement was
66.8 mm, and interantegonial notch width was 96.0
mm, with resultant a maxillomandibular differential of
29.2 mm (Table).
TREATMENT OBJECTIVES
The treatment objectives were to (1) correct the
maxillary deficiency with sufficient maxillary expan-
sion, (2) maintain sound periodontal support in the
maxillary arch throughout treatment, (3) establish an
esthetic profile with maxillomandibular orthognathic
surgery, and (4) establish proper buccal occlusion.
832 Lee et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2010

Fig 3. Pretreatment casts.

Fig 4. Pretreatment x-rays (lateral cephalogram and
panoramic x-ray).
TREATMENT ALTERNATIVES
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-
traction would have prolonged the overall treatment.
The increase in the negative overjet after maxillary
American Journal of Orthodontics and Dentofacial Orthopedics 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
months.

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-
ity of orthopedic expansion is greatly reduced after 15
years of age, when SARPE may have to be used.3,10
However, the validity of surgical or nonsurgical
treatment should be reexamined in terms of feasibility,
safety, and stability.
Early histologic studies showed that palatal suture
obliteration or synostosis begins when people are in
their thirties, and fusion of facial sutures is rare in older
skulls, unlike the cranial sutures,11-15 which were
sion in the midpalatal suture was rare in subjects under
25 years. These findings substantiate anecdotal case re-
ports in which conventional RPE produced successful
orthopedic effects.5
Nevertheless, a recent study showed that nonsurgi-
cal expansion even in prepubertal patients leads to thin-
ning of the buccal alveolar wall, which could develop
a bony dehiscence.17 This effect was more evident in pa-
tients with tooth-borne expanders than tooth-and-tissue-
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
conventional expanders. Taken together, the maximum
skeletal effect during and after expansion is a crucial
factor whether the expansion is surgical or nonsurgical.
Although surgical osteotomies obviously allow
maxillary skeletal expansion in adults, there have been
controversial opinions about the stability of the arch
width. Phillips et al9 reported considerable relapse after
expansion with LeFort I and segmental osteotomy in 39
patients. SARPE, therefore, was expected to show supe-
rior stability compared with segmental osteotomy, since
it allows tissue adaptation during the expansion and
subsequent consolidation period. However, an empirical
comparison between SARPE and nonsurgical expan-
sion has been difficult, mainly because of the problems
in designing a controlled experiment between age-
matched groups.18,19 Berger et al20 stated that the
1-year stability of SARPE in postpubertal subjects was
not significantly different from that of nonsurgical ex-
pansion in prepubertal patients. Therefore, it can be
speculated that the treatment effects and the stability
of nonsurgical expansion in adults are comparable
with those of SARPE, when the orthopedic expansion
is secured.
Diagnostic criteria for surgical intervention have
been suggested in several ways. Handelman et al6 stated
that surgically assisted expansion should be used when
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
width differential measured from the PA view, as a guide
for surgical expansion. According to those criteria, our
patient would need 2-stage surgery. However, Bailey
et al18 favored simultaneous segmental osteotomy and
mandibular surgery over 2-stage surgery in long-face
patients with narrow maxillae, due to surgical trauma,
morbidity, and cost. Thus, nonsurgical expansion may
be justified when it leads to treatment effects similar to
those of SARPE.
MARPE is a simple modification of the conven-
tional RPE appliance; the main difference is the incor-
poration of several miniscrews to ensure expansion of
the underlying basal bone and maintain the separated
bones during the consolidation period. Posterior minis-
crews were placed close to the midpalatal suture to use
the bone thickness of the nasal crest.22,23 The treatment
effects in this case can be defined as a combination of
skeletal and dentoalveolar expansion, since the
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
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
with SARPE,24 and the amount of expansion at the max-
illary basal bone was not as much as the dentoalveolar
expansion.25 A triangular expansion represented by
greater dentoalveolar expansion with less basal bone ex-
pansion seems unavoidable because of the anatomic
structure and the appliance design, whether the expan-
sion is surgical or nonsurgical.
Some bone-borne maxillary expanders have been
proposed in reports to facilitate the skeletal expansion
following lateral osteotomies.26-28 In contrast, our
tooth-and-bone-borne appliance required a simple proce-
dure for miniscrew placement and definitely did not need
an osteotomy, implying that an effective replacement of
SARPE with MARPE in young adults may be possible.
In spite of our promising clinical results, the
MARPE appliance cannot be expected to force the sep-
aration of obliterated sutures in older adults. Therefore,
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
of choice for older patients.18 The primary objective
of the appliance is to gain maximum skeletal effects
in the patent sutures but not necessarily in the obliter-
ated sutures. Possible mechanical resistance from the
circummaxillary sutures could be another limiting fac-
tor even when the suture is patent.4 Because of the var-
iations in suture development and the complexity of
craniofacial structures, a prospective study needs to be
conducted to evaluate the reliability of this appliance
in adults compared with growing children.
American Journal of Orthodontics and Dentofacial Orthopedics
June 2010
CONCLUSIONS
This case report introduced an RPE reinforced by
orthodontic miniscrews (MARPE) positioned on the
palatal bone. It demonstrated the clinical effects in treat-
ing a young adult with severe maxillary constriction and
mandibular prognathism. To avoid multiple surgeries,
nonsurgical maxillary expansion was performed with
the MARPE to achieve both skeletal and dentoalveolar
expansion for transverse correction. Subsequent orthog-
nathic surgery corrected the mandibular prognathism
and vertical excess. The stability of the expansion and
the periodontal status were favorable from the follow-
up clinical and radiologic findings. This report proposes
effective incorporation of orthodontic miniscrews for
transverse correction; this can eliminate the need for
multiple surgeries in patients with complex craniofacial
discrepancies and secure the safety and stability of the
transverse correction.
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