CASE REPORT

Treatment of a Class III malocclusion with

maxillary hypoplasia in late puberty using
palatal expansion supported by
miniscrews and fixed appliances
Xiaohuan Zhong, Xuhua Yao, Baihui Liu, and Huixin Wang
Hunan, China

This case report presents an orthodontic treatment that successfully improved the facial profile of a thir-
teen-and-a-half-year-old girl who had a severe concave profile. The treatment included palatal expansion
assisted with miniscrews and fixed appliance therapy but without maxillary protraction. Active treatment
lasted for 42 months. As a result, Class I occlusion with a harmonized profile was achieved with no adverse
effects. Residual maxillary growth, clockwise rotation of the mandible, and correction of excessive lingual
inclination of the mandibular incisors are important factors for improving facial profile. (Am J Orthod
Dentofacial Orthop Clin Companion 2022;2:192–203)

S keletal Class III malocclusion is a complex cranio-

maxillofacial abnormality that has been widely docu-
mented, it presents as either maxillary hypoplasia,
mandibular prognathism, or a combination of both.1,2
Anterior crossbite and an unesthetic concave profile are
often the main reasons patients seek treatment. When
skeletal disharmony is mild or moderate in adolescence, a
better occlusion and esthetic profile can be obtained with
camouflage orthodontic treatment or combined orthope-
dic correction.3-5 However, when it occurs to a severe
degree, surgical intervention is often needed to achieve an
ideal facial profile and occlusion.3,6,7
Maxillary hypoplasia, in addition to mandibular progna-
thism, is often the primary etiology of a concave profile.
Maxillary hypoplasia is often accompanied by a transverse
discrepancy, characterized by a narrow maxillary basal
arch and a compensatory inclination of the posterior teeth.
Rapid maxillary expansion (RME) has been demonstrated
to effectively open the midpalatal suture; thus, it is widely
Department of Orthodontics, Center of Stomatology, Xiangya
Hospital, Central South University, Changsha, Hunan, China.
All authors have completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest, and none were
reported.
Address correspondence to: Huixin Wang, Department of
Orthodontics, Center of Stomatology, Xiangya Hospital, Cen-
tral South University, Changsha 410008, Hunan, China; e-mail,
wanghuixin114@126.com
used to correct maxillary transverse deficiency in adoles-
cents. However, it simultaneously causes some disadvan-
tages when using teeth as an anchorage, such as severe
buccal inclination of the posterior teeth and bone
dehiscence.8,9 To prevent these adverse effects, skeletal
anchorage has recently been used in patients. With the
help of RME supported by miniscrews, more orthopedic
effects, rather than dental effects, have been achieved in
practice.10,11
The maxillary expansion-protraction protocol, com-
bined routinely with subsequent fixed appliance therapy,
has been proven to be an effective method to correct max-
illary hypoplasia in growing patients.3,12 Since the introduc-
tion of the alternating RMEs and constrictions (Alt-RAMEC)
protocol by Liou and Tsai,13 which is known for its ability to
effectively release the circummaxillary suture, this proto-
col has been used in recent years, in combination with
maxillary protraction, in the treatment of Class III maloc-
clusion with maxillary hypoplasia in adolescents.14,15
In this case report, we present a patient in late puberty
with maxillary hypoplasia, transverse deficiency, and man-
dibular prognathism, treated with a palatal expansion
appliance (a modified Alt-RAMEC protocol supported by
miniscrews) and, simultaneously, with a fixed appliance
therapy without maxillary protraction. Interestingly, the
maxillary hypoplasia markedly improved after treatment,
and subsequent favorable dental and esthetic facial results
were achieved.

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Fig 1. Pretreatment facial and intraoral photographs.
DIAGNOSIS AND ETIOLOGY
The patient was a thirteen-and-a-half-year-old girl with
a chief complaint of “a lower front teeth bite in front of the
maxillary teeth, and a strange face shape.” A concave pro-
file with mandibular prognathism, retrusive upper lip, and
high tension in the labiomental fold was noted in the
patient. A mild chin shift to the right side was identified on
frontal view. The vertical facial proportions were slightly
disharmonious, presenting a shorter lower anterior facial
height. The smile line was unesthetic because of an ante-
rior crossbite and excessive exposure of the mandibular
incisors (Fig 1). Her parents confirmed no family history of
skeletal Class III malocclusion, and there was no history of
temporomandibular joint dysfunction.
Intraoral examination showed an anterior crossbite and
a posterior crossbite on the right side; the overjet and
overbite were 2.1 and 3.7 mm, respectively. Canines and
molars showed a Class III malocclusion relationship on
both sides. The maxillary dental midline was 1.0 mm left of
the facial midline, whereas the lower midline was shifted
2.5 mm toward the right of the facial midline (Fig 1). Cast
analysis showed 4 mm crowding in the maxillary arch and
2 mm crowding in the mandibular arch (Fig 2). When the
patient’s mandible was guided into a centric relation, the
mandible was able to move back slightly from the incisor’s
edge-to-edge (Fig 3).
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Zhong et al.
The initial panoramic image showed a permanent denti-
tion with all of the third molar germs. Lateral cephalomet-
ric analysis revealed a skeletal Class III malocclusion with
a deficient maxilla and a hyperdivergent growth pattern.
The inclination of the maxillary incisors was within the nor-
mal range, whereas the mandibular incisors were retro-
clined in the patient (Fig 4; Table I). The morphology of the
cervical vertebrae (CS6 stage) suggested that the patient
was in a growth deceleration period. She was diagnosed
with an Angle Class III malocclusion with maxillary hypo-
plasia in the anteroposterior dimension.
TREATMENT OBJECTIVES
The treatment objectives were to (1) resolve the transverse
skeletal and dental discrepancies, (2) correct the crossbite,
dental crowding, and midline discrepancy, (3) establish a
Class I canine and molar relationship, and (4) correct the con-
cave profile to obtain an esthetic facial profile.
TREATMENT ALTERNATIVES
Orthognathic surgery was suggested for this patient as
it would lead to a harmonized profile, good lip-teeth rela-
tionship, and normal inclination of the teeth. However, the
patient and her family refused the surgical plan for finan-
cial reasons and the potential risk involved during surgery.
Before coming to our clinic, an expansion-facemask
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Zhong et al.

Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment occlusion at centric relation.

approach had been recommended to the patient by other

dental clinics; however, the patient refused this approach
because of its appearance. Therefore, we did not recom-
mend this approach to the patient. Another option
involved palatal expansion assisted with miniscrews to cor-
rect the transverse discrepancy and posterior crossbite.
The anterior crossbite could be resolved using two means.
First, the mandibular incisors could be tipped back by
closing the extraction spaces with the extraction of the
premolars (or mandibular second molars) or moving the
mandibular arch distally with miniscrews (extraction of the
mandibular third molars).16,17 Alternatively, we could cor-
rect the anterior crossbite by taking advantage of the
residual maxillary growth, proclination of the maxillary
incisors, and clockwise rotation of the mandible (mandibu-
lar clockwise rotation occurred when the incisors were
edge-to-edge in centric relation), which would likely
improve the concave profile and change the morphology of
the geniolabial sulcus. Extraction of redundant third
molars was proposed in this patient. After discussing these Fig 4. Pretreatment radiographs: lateral cephalogram,
options with the patient, the second treatment plan was cephalometric tracing, and panoramic radiograph.

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 Zhong et al.

Table I. Cephalometric Measurements

Measurements Norm § SD Pretreatment After expansion Posttreatment

Sagittal
SNA (°) 82.0 § 3.5 72.0 73.0 74.6

SNB (°) 80.9 § 3.4 76.3 74.4 74.9

ANB (°) 1.6 § 1.5 4.3 1.4 0.3

A-NPo (mm) 0.7 § 2.0 3.6 2.0 1.7

Wits (mm) 1.0 § 1.0 8.5 4.8 2.9

Vertical
MP-FH (°) 23.9 § 4.5 32.1 34.6 34.5

MP-SN (°) 33.0 § 6.0 43.2 45.5 45.3

Y-axis (°) 67.0 § 5.5 73.9 75.6 75.5

Occ Plane-FH (°) 6.8 § 5.0 10.7 9.0 7.7

Anterior Facial Height (N-Me) (mm) 128.5 § 5.0 107.3 112.2 112.0

Posterior Facial Height (S-Go) (mm) 82.5 § 5.0 63.2 63.5 64.9

ANS-Me/N-Me (%) 55.0 § 0.1 51.4 53.0 52.7

Growth amount
Anterior Cranial Base (S-N) (mm) 62.6 § 3.2 57.6 57.6 57.9

Mandibular Body Length (Go-Gn) (mm) 75.2 § 4.4 71.1 71.2 72.2

Dental
U1-SN (°) 102.8 § 5.5 98.6 110.0 109.7

L1-MP (°) 95.0 § 7.0 74.2 75.1 83.4

U1-L1 (°) 130.0 § 6.0 144.1 129.3 121.5

Overjet (mm) 2.5 § 2.5 2.1 1.2 2.6

Overbite (mm) 2.5 § 2.0 3.7 0.3 1.3

Soft tissue
Upper Lip to E-Plane (mm) 4.9 § 2.0 9.0 2.9 2.8

Lower Lip to E-Plane (mm) 2.0 § 2.0 0.7 0.6 0.2

Nasolabial Angle (°) 102.0 § 8.0 69.9 99.0 93.7

adopted, and consent was obtained from the patient and in the mandibular arch to eliminate possible lateral man-
her parents. dibular functional displacement and relieve anterior cross-
bite. The RME appliance consisted of 4 miniscrews
TREATMENT PROGRESS (1.4 £ 8 mm ), an expansion screw, and an acrylic resin
All third molars were extracted during treatment. The body. Under local anesthesia, 2 miniscrews were inserted
maxillary arch was bonded and aligned with a sequential between the second premolar and the first molar, and the
wire from 0.012-in nickel-titanium (NiTi) to other 2 were inserted between the first and second molars,
0.019 £ 0.025-in stainless steel (SS). An occlusion splint which were connected to the appliance by adding resin
(fabricated from centric relation mounted models) with (Fig 5). The Alt-RAMEC protocol was used to correct the
moderate canine guidance and incisal guidance was used maxillary transverse deficiency, as described previously.17

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Zhong et al.

Fig 5. Hybrid type C-expander with palatal mini-implants.

Fig 6. Lateral cephalograms and superimpositions of lateral cephalograms at 1-month consolidation after the expansion (black,
pretreatment; blue, 1-month consolidation after the expansion).

The screw was opened by turning 1 mm/d (2 activations in
the morning and 2 activations in the evening) during the
first week and closed 1 mm/d during the following week.
This alternating opening and closing were repeated for 9
consecutive weeks, and an improvement in the transverse
discrepancy was clinically observed in the patient.
The anterior crossbite was corrected after expansion,
after which the mandibular arch was bonded and aligned
with a sequential wire from the 0.012-in NiTi to the
0.019 £ 0.025-in SS (Fig 6). At 15 months, the posterior
and anterior crossbites were corrected, and the midline
was partly adjusted in the patient. The expander and 4 pal-
atal miniscrews were then removed accordingly. A
miniscrew was inserted between teeth no. 15 and no. 16 to
correct the deviated maxillary arch midline with elastic
traction (Fig 7).
After 30 months, the maxillary and mandibular midline
deviations were corrected, positive overjet and overbite
were achieved, and Class I occlusion was established on
both sides. To further correct the inclination of the man-
dibular incisors, short Class II elastics (3/16-in, 3.5 oz)
were used with 0.019 £ 0.025-in SS wires. During the fin-
ishing stage, final occlusion was achieved with
0.018 £ 0.025-in NiTi wires in the maxillary arch and
0.019 £ 0.025-in SS wires in the mandibular arch. Vertical
elastics (3/16-in, 3.5 oz) were applied on both sides to

Fig 7. Intraoral photographs during orthodontic treatment.

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 Zhong et al.

Table II. Transverse width of the maxillary arch and buccolin- maxillary skeletal base and a clockwise rotation of the
gual inclination of maxillary molars mandible (Fig 6; Table I).
Treatment objectives were achieved after active treat-
Variables Pretreatment Posttreatment ment. Furthermore, Class I occlusion with proper overbite
and overjet was achieved in this patient (Fig 8). As the
Intercanine width 36.0 38.0 lower anterior facial height increased because of the clock-
(mm) wise rotation of the mandible, the patient had a satisfac-
Intermolar width 46.0 53.0 tory appearance with a straight profile and an attractive
(mm) chin contour. Both the smile esthetics and the midline
irregularity of the dental arch improved (Fig 8). No tempo-
Buccolingual incli- 1.8 1.5
romandibular joint pain or discomfort was reported during
nation-R (mm)
or after orthodontic treatment. The patient and her parents
Buccolingual incli- 2.5 1.4 were satisfied with the occlusion and facial profile
nation-L (mm) achieved without orthognathic surgery.
Maxillary expansion was achieved after treatment. In
the maxillary arch, the intercanine width expanded from
correct the open bite in the molar region. Active treatment
36 to 38 mm, whereas the intermolar width expanded from
lasted 42 months for treatment stability. After debonding,
46 to 53 mm without further tipping of the maxillary molar
we prescribed transparent retainers that the patient had
buccally (Figs 2, 9, and 10; Table II). The posttreatment
to wear the entire day for the first 6 months and then only
panoramic radiograph showed no significant root resorp-
during the night for the next 12 months.
tion or other pathologic findings. No gingival recession was
observed in the anterior mandibular region. Lateral cepha-
lometric analysis showed skeletal changes with a forward
TREATMENT RESULTS movement of the maxillary skeletal base after treatment
The anterior crossbite was corrected in the patient after (SNA, 2.6°) and a clockwise rotation of the mandible (SNB,
a 1-month consolidation period after expansion. Lateral 1.4°). This was the main cause of the correction for the
cephalometric analysis showed a forward movement of the relationship between the maxilla and mandible and the

Fig 8. Posttreatment facial and intraoral photographs.

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Fig 9. Posttreatment dental casts.

alteration of the Wits value. The SNB change might be DISCUSSION

explained by mandibular clockwise rotation (Mp-FH, 2.4°),
combined with the growth of the mandible (the mandibular
body length increased by 1.1 mm). The maxillary incisors
were more proclined (SN-U1, 11.1°) to correct the anterior
crossbite, in addition to which the mandibular incisors
were also proclined (L1-Mp, 9.2°) to achieve a better men-
tolabial form (Figs 11 and 12; Table I). Skeletal change can
be seen on the superimposition of the cone-beam com-
puted tomography (CBCT) images (Fig 12, B). At the 18-
month posttreatment follow-up, the occlusion remained
stable, although there was a slight decrease in the buccal
overjet at the posterior teeth compared with that right
after active treatment (Fig 13). Cephalometric tracing
showed that the jaw growth was almost complete (Fig 14).
The patient was satisfied with the occlusion and facial
esthetics.
This patient is interesting because we obtained good
esthetic dental and facial results in an adolescent, growing
patient without surgery. There are several points to be dis-
cussed in this case report.
For patients with skeletal Class III malocclusion, surgi-
cal treatment results in a normal jaw relationship, a more
attractive profile and a more favorable lip and chin con-
tour.18 Although orthognathic surgery was suggested to
this patient for her apparent concave facial profile, it was
rejected. Eslami et al19 suggested that orthognathic sur-
gery should be applied to adult patients with Class III mal-
occlusions with H-angle <10.3° and Wits appraisal under
5.8 mm. In this patient, both the H-angle (4.1°) and Wits
appraisal ( 8.5 mm) were within the range that would
suggest the applicability of orthognathic surgery. However,
several mitigating factors suggested that pure orthodontic

Fig 10. Images of CBCT taken before and after treatment. The reference line was tangential to the maxillary mesial lingual cusp at the
most inferior level. The inclination of the maxillary first molar (A, pretreatment; B, posttreatment) was measured as the distance
between the reference line and the maxillary mesial buccal cusp.

198 AJO-DO CLINICAL COMPANION


Fig 11. Posttreatment radiographs: lateral cephalogram, cephalometric tracing, and panoramic radiograph.
treatment could be a viable choice. Tweed20 and Moyers21
categorized Class III malocclusion into pseudo-Class III
malocclusion, characterized by an anterior crossbite
caused by a forward functional displacement of the mandi-
ble and skeletal Class III malocclusion. This means that the
mandibular position may play an indispensable role in
deciding the appropriate treatment plan. This adolescent
female patient had a discrepancy between the centric
occlusion and maximum intercuspal occlusion. When her
jaw was guided into a centric relationship, she showed an
end-to-end incisor relationship accompanied by alleviation
of sagittal skeletal discrepancy. Although the patient
showed obvious maxillary retrusion and was in a growth
deceleration period, residual maxillary growth would likely
yield promising results.
In this patient, a type of C-expander supported by four
miniscrews, a bone-borne appliance, was used to correct
the maxillary transverse deficiency and avoid the disadvan-
tages of conventional tooth-anchored maxillary expand-
ers.8-11 Because the C-expander was not attached to the
teeth, the dentition could be aligned and leveled with fixed
appliances during palatal expansion. As a result of maxil-
lary expansion, the transverse discrepancy was corrected
in the patient. In addition, CBCT images taken before and
after the treatment showed no further buccal tipping of
the maxillary right posterior teeth and a reduction in the
April 2022, Vol 2, Issue 2
Zhong et al.
buccal inclination of the maxillary left posterior teeth
(Fig 10). The reduction resulted from the decompensation
of the buccal inclination to coordinate the arch width of
the left side after expansion. During the retention period,
there was a decrease in the buccal overjet at the posterior
teeth compared with that right after active treatment. This
relapse might have been caused by the higher buccal pres-
sure than the lingual pressure.22
In general, orthopedic intervention with an expan-
sion-facemask approach is recommended for patients
with skeletal Class III with maxillary hypoplasia before
their pubertal growth peak to obtain maximum skeletal
changes.3,23 However, there is a precedent described in
previous studies that patients in the later stage of
puberty could also be treated with facemask therapy
with satisfactory results.24 Our patient did not undergo
facemask therapy, despite being a good candidate for
this procedure. Liou and Tsai13 reported that the max-
illa moved forward (point A, 3 mm) after maxillary
expansion with the Alt-RAMEC protocol in patients with
a cleft and noticed a larger amount of maxillary for-
ward movement related to the Alt-RAMEC protocol
than that related to the traditional RME. However, in
this case, SNA increased by only 1° in the first month of
consolidation after treatment with this protocol, which
was similar to the findings of Yilmaz and Kucukkeles.25
199
Zhong et al.
Fig 12. A, Tracings and superimpositions of lateral cephalograms (black, pretreatment; red, posttreatment). B, Images and
superimpositions of reconstructed CBCT images (gray, pretreatment; green, posttreatment). The superimpositions were done using
Dolphin software (version 11.8; Dolphin Imaging and Management Solutions, Chatsworth, Calif).
To correct the concave profile with mandibular progna-
thism, the treatment plan could include a clockwise rota-
tion of the mandible, which could be done by wearing a
splint full-time for 3 months. This would increase the ante-
rior facial height and rotate the mandible clockwise, thus
making the chinless prominent26 This is an undesirable
effect seen in patients with hyperdivergent skeletal pat-
terns. Moreover, patients with Class III malocclusion with a
hyperdivergent skeletal pattern generally respond poorly
to treatment.27 However, in our patient, although present-
ing with a hyperdivergent skeletal pattern, the patient had
a shorter lower anterior facial height. An increase in the
lower anterior facial height to help acquire appropriate
facial proportions was essential for obtaining an attractive
profile for this patient. After treatment, cephalometric
superimposition showed a mandibular clockwise rotation
and an increase in the lower anterior facial height
(although still below the normal range), whereas the
patient showed an esthetic facial profile. In this patient,
clockwise rotation of the mandible helped correct the
anterior crossbite and mandibular prognathism. Unlike
some camouflage treatments that excluded the undesired
mandibular growth that would reduce the stability of the
treatment, moderate mandibular growth in this patient
was expected to improve the unesthetic chin contour after
200
clockwise rotation of the mandible (Fig 15). After treat-
ment, a straight profile was achieved, partly because of
mandibular growth. Although the mandible rotated clock-
wise, cephalometric superimposition between posttreat-
ment and 18-month follow-up showed stability of the
treatment results (Fig 14). This might be due to the
patient’s growth being roughly complete, and a normal
occlusal relationship of the posterior teeth was established
with extrusion of the maxillary molars.
Insufficient width of the maxillary arch is the most fre-
quent cause of unilateral posterior crossbite, often accom-
panied by a functional lateral shift of the mandible in
children, and this functional lateral shift is usually elimi-
nated with early expansion therapy.28,29 The superimposi-
tions of reconstructed 3-dimensional CBCT images
indicated a slight left shift of the mandible after treatment,
which might be due to the increase in the maxillary width
and the correction of the posterior crossbite on the right
side (Fig 12).28,29 This was also an important factor in
obtaining a more esthetic facial profile.
In general, camouflage treatment of Class III malocclu-
sion included retroclination of the mandibular incisors
with or without proclination of the maxillary incisors. In
addition to the maxillary deficiency and retruded upper lip,
the maxillary incisors of this patient were proclined to
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 Zhong et al.

Fig 13. Facial and intraoral photographs at the 18-month postretention follow-up.

compensate for the maxillary development deficiency and
plump the upper lip. The linguoversion of mandibular inci-
sors was already compensated for in the patient; thus,
they could not be further tipped back to compromise the
overjet. Therefore, although Class III elastics are commonly
used in orthodontic treatment, they were not considered in
this patient because of the retroclination of the mandibular
incisors. After clockwise rotation of the mandible, the
patient’s mentolabial fold appeared flattened, which in
turn led to a worsened lower lip profile. Previous studies
have confirmed that retraction of the mandibular incisors
helps deepen the mentolabial fold, which is essential for

Fig 14. Lateral cephalogram at the 18-month retention follow-up, cephalometric superimposition (red, posttreatment; green,
postretention).

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Zhong et al.
Fig 15. Profile changes: A, Pretreatment; B, After one-year treatment; C, Posttreatment.
improving lip curvature in patients with Class III
malocclusion.17,30 However, in this patient, a proper men-
tolabial sulcus and esthetic chin contour were achieved by
proclination of the mandibular incisors via labial inclining,
aligning the mandibular incisors, and using short Class II
elastics in the late stage of the treatment. Cephalometric
superimposition indicated that it was because of the pro-
clination of the mandibular incisors that a deeper labio-
mental fold was seen in the patient. This finding was
similar to that obtained in the study of Yanagita et al30 in
that, although the mandibular incisors showed retraction
after the extraction of the premolars, they were also pro-
clined. Therefore, we speculate that correcting excessive
lingual inclination of the mandibular incisors will help to
improve chin contour in camouflage treatment of skeletal
Class III malocclusion.
Class III elastics were also not considered in this patient
because extrusion of the mandibular incisors would aggra-
vate the excessive exposure of the mandibular incisors. In
addition, these vertical changes induce counterclockwise
rotation of the occlusal plane (OP). Cephalometric super-
imposition showed a counterclockwise rotation of the OP
after treatment (3°), with no extrusion of the mandibular
incisors, although the mandible moved in a clockwise
direction. This OP rotation mainly resulted from the extru-
sion of the maxillary molars. The mild counterclockwise
rotation of the OP did not affect smile attractiveness.31
Comparing the pretreatment and posttreatment photo-
graphs, the patient’s smile esthetics were improved, which
was most likely the result of the improvement of the maxil-
lary hypoplasia and reduced the exposure of the mandibu-
lar incisors.32,33
Although the treatment was performed without maxil-
lary protraction or orthognathic surgery, the results were
satisfactory, including favorable dental occlusion and an
esthetic facial profile within the parameters of camouflage
202
treatment. The patient and her parents were satisfied with
the treatment results despite the active treatment period
lasting 42 months.
CONCLUSIONS
Despite our acceptable clinical results, it may have
been better if the patient had accepted treatment with a
facemask. Facemask treatment may have further pro-
tracted the maxilla, avoided excessive proclination of the
maxillary incisors, and shortened the treatment time. The
Alt-RAMEC protocol alone in this patient had no significant
effect on the improvement of maxillary retrognathia. Resid-
ual maxillary growth and clockwise rotation of the mandi-
ble are important factors for improving the patient’s facial
profile. In addition, the lower third of the facial profile was
improved with a deepened labiomental fold by proclination
of the mandibular incisors.
ACKNOWLEDGMENTS
The authors thank Elsevier Language Editing Services
for the English language editing and review services.
AUTHOR CREDIT STATEMENT
Xiaohuan Zhong contributed to conceptualization and
methodology, Xuhua Yao contributed to data curation and
original draft preparation, Baihui Liu contributed to investi-
gation and resources, and Huixin Wang contributed to
supervision and manuscript review and editing.
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