PMC6305058_01
Initial intraoral images: (a) right side, (b) frontal, (c) left side, (d) occlusal view of upper arch, and (e) occlusal view of lower arch.
CRID2018-1392895.001.jpg
PMC6305058_01_CRID2018-1392895.001.jpg
fig1
Intraoral photos showed canines in Class I relationship with unilateral crossbite on the right side, 1 mm overjet, 2 mm overbite, triangular shape of the upper arch, and oval shape in the lower arch (Figure 1).
Lateral X-ray (a). Panoramic X-ray (b).
CRID2018-1392895.002.jpg
PMC6305058_01_CRID2018-1392895.002.jpg
fig2
Lateral and panoramic x-rays show good inclination of upper incisors, lower incisors slightly proclined, and absence of all third molars (Figure 2).
Ricketts cephalometric and soft and hard tissue integration analyses.
CRID2018-1392895.003.jpg
PMC6305058_01_CRID2018-1392895.003.jpg
fig3
Lip sealing was presented (Figure 3).
MARPE in place and minimally invasive surgical procedure to reduce suture resistance: (a) day of installation; (b) after corticopuncture procedure (8 perforations); (c) corticopuncture method:first stage: shallow predrilling using lance; and (d) corticopuncture method:second stage: insertion and removal of the miniscrew (4-5 mm depth).
CRID2018-1392895.004.jpg
PMC6305058_01_CRID2018-1392895.004.jpg
fig4
Initial orthodontic planning was to perform rapid palatal expansion with bone anchorage (Figure 4(a)). After failing to activate the MARPE device, a minimally invasive surgical method was suggested to the patient in order to reduce suture resistance and accelerate bone remodeling (Figures 4(b)-4(d)).
Cone beam CT image of the corticopunctures for an illustration purpose: (a) sagittal view and (b) axial view.
CRID2018-1392895.005.jpg
PMC6305058_01_CRID2018-1392895.005.jpg
fig5
In the anterior part of the palate perforations were done carefully in order to avoid the nasopalatine canal (Figure 5).
Protocol of the corticopuncture procedure suggested prior MARPE insertion in a second patient: (a) nerve block anesthesia, (b) corticopuncture procedure performed using contra-angle electric screwdriver, (c) maxillary skeletal expander in place and miniscrew insertion, (d) end of procedure, (e) result after expansion, and (f) occlusal X-ray showing midpalatal suture split.
CRID2018-1392895.006.jpg
PMC6305058_01_CRID2018-1392895.006.jpg
fig6
Figure 6 shows a step-by-step corticopuncture method in a second patient who was treated using 11 mm Maxillary Skeletal Expander I (MSE) (Biomaterials Korea, Seoul, South Korea) and 4 miniscrews (11 mm in length and 1.5 in diameter). For this patient, a contra-angle electric screwdriver (Model ISD900, NSK, Japan) set in 25 min-1 speed and 40 Ncm torque was used to perform the corticopunctures.
Images of the result after the corticopuncture procedure and second activation protocol: (a) right, (b) frontal, (c) left, (d) upper occlusal view after opening of the medial palatine suture, and (e) upper occlusal X-ray.
CRID2018-1392895.007.jpg
PMC6305058_01_CRID2018-1392895.007.jpg
fig7
A diastema between incisors was then observed (Figure 7).
CBCT images after MARPE and corticopuncture procedure: (a, b) 3D reconstructed image in frontal view before and after expansion; (c, d) axial section of the maxilla at the level of anterior and posterior nasal spine before and after expansion; (e) coronal section at the level of the upper first molars showing suture split and molar inclination; and (f) sagittal section showing the bicortical anchorage of the miniscrews.
CRID2018-1392895.008.jpg
PMC6305058_01_CRID2018-1392895.008.jpg
fig8
An image in a sagittal view close to the microimplants showed that both were anchored in a bicortical engagement of the palate and the nasal cavity floor as recommended by Lee et al. (Figure 8).
Orthodontic phase of the treatment: (a) frontal, (b) overjet, (c) right, and (d) left.
CRID2018-1392895.009.jpg
PMC6305058_01_CRID2018-1392895.009.jpg
fig9
Final pictures: (a) frontal, (b) overjet, (c) right, (d) left, and (e, f) retention appliance with temporary crowns.
CRID2018-1392895.010.jpg
PMC6305058_01_CRID2018-1392895.010.jpg
fig10
Since spaces were prepared for rehabilitation, the patient was referred to implantology and prosthodontics (Figure 10).
Facial images during smile before, immediately after suture split (presence of the anterior diastema), and after treatment.
CRID2018-1392895.011.jpg
PMC6305058_01_CRID2018-1392895.011.jpg
fig11
Figure 11 shows broader smile compared to the initial. Facial photographs during smiling showed before and after suture split, the presence of a diastema between the central incisors immediately after corticopuncture procedure and MARPE reactivations. Final pictures shows an improvement in buccal corridor during smile and also mandibular deviation (Figure 11).