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Clinical case 1: initial pictures of face and intraoral images.
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A 15 years and 4 months old patient presented with reduced incisor display during smile (Figures 1 and 2).
Clinical case 1: initial lateral head film (A), cephalometric tracing (B) and panorex (C).
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A 15 years and 4 months old patient presented with reduced incisor display during smile (Figures 1 and 2).
Positioning of MSE virtual model (A) on the integrated model of patient CBCT and digital model of maxillary dental arch. (B) Occlusal view. (C) Measurement of bone thickness at the level of left miniscrews. (D) Measurement of bone thickness at the level of right miniscrews. (A) is reproduced with permission from Dove Medical Press. Cantarella D, Savio G, Grigolato L, et al. A new methodology for the digital planning of micro-implant-supported maxillary skeletal expansion. Med Devices Evid Res. 2020;13:93-106.
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A virtual model of MSE appliance with 4 miniscrews was imported in Real Guide software, as described in a previous publication and the palatal bone thickness was assessed with the software ruler (Figure 3).
Bushing and miniscrew utilized for lateral positioning between second premolar and first molar. (A) Virtual model. (B) Physical bushing produced with selective laser melting technology and conventional prefabricated miniscrew. (C) 0.010 steel ligature tie between head of miniscrew and bushing pin. Adapted with permission from Cantarella D, Quinzi V, Karanxha L, Zanata P, Savio G, Del Fabbro M. Digital workflow for 3D design and additive manufacturing of a new miniscrew-supported appliance for orthodontic tooth movement. Appl Sci. 2021;11.
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The virtual model of two bushings with miniscrews inside (Figure 4), was imported in Real Guide software. For the 2 lateral miniscrews, a 0.010 steel ligature was tied from the miniscrew head to a pin present on the bushing (Figure 4C), and then covered with Flow composite material (Figure 7).
Positioning of virtual model of additional lateral bushings and miniscrews on the patient integrated model. (A) Occlusal view. (B) View from top, after isolating dental crowns and roots. (C) Coronal view with measurement of bone thickness at the level of additional lateral miniscrews.
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Miniscrews were positioned in the patient CBCT where the bone thickness was greater, on the palatal side of alveolar processes, between second premolars and first molars (Figure 5).
Virtual model of cad-cam structure. (a) MSE body. (b) Bushing for lateral miniscrew. (c) Pin for steel ligature tie. (d) Connecting arm between bushing and MSE body. (e) Connecting arm between bushing and molar band. (f) Cad-cam molar band.
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The connecting arms bridged from the bushings to the MSE body and to the molar bands (Figure 6).
Positioning of MSE appliance in the oral cavity. (A) After cementation of molar bands. (B) After positioning of 6 miniscrews and tie with 0.010 steel ligature between head of lateral miniscrew and bushing pin. (C) After positioning of composite flow on top of lateral miniscrew heads and bushings.
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For the 2 lateral miniscrews, a 0.010 steel ligature was tied from the miniscrew head to a pin present on the bushing (Figure 4C), and then covered with Flow composite material (Figure 7).
Patient records after maxillary expansion. (A) Intraoral occlusal picture. (B) Intraoral frontal picture. (C) CBCT axial palatal section. (D) 3D rendering of maxilla. (E) CBCT coronal section through the 2 additional lateral miniscrews.
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Two activations per day (0.267 mm expansion) were done with a total activation of 7 mm (Figure 8). Lateral miniscrews were away from the roots of first molars and second premolars, as shown in a coronal section of the CBCT (Figure 8E).
Maxillary protraction with facemask at night-time (A) and with intraoral elastics from a modified lingual arch to maxillary molar bands (B-F) during day-time.
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The patient promoted a maxillary protraction with elastics (3/8", 16 ounces) from the facemask to the MSE hooks at night-time and with Class III intraoral elastics (3/16", 6 ounces) from the modified lower lingual arch to the maxillary molar bands at day-time (Figure 9), until achievement of slight Class II molar and canine relationship (Figure 10).
Facial and intraoral pictures after maxillary protraction.
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The patient promoted a maxillary protraction with elastics (3/8", 16 ounces) from the facemask to the MSE hooks at night-time and with Class III intraoral elastics (3/16", 6 ounces) from the modified lower lingual arch to the maxillary molar bands at day-time (Figure 9), until achievement of slight Class II molar and canine relationship (Figure 10).
PMC8504975_02
Clinical case 2: initial pictures of face and intraoral images.
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A 33-year-10-month-old female patient presented with the chief complaint of a midline shift in her upper dental arch (Figures 11 and 12).
Clinical case 2: initial lateral head film (A), cephalometric tracing (B) and panorex (C).
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A 33-year-10-month-old female patient presented with the chief complaint of a midline shift in her upper dental arch (Figures 11 and 12).
Positioning of MSE virtual model on the integrated model of patient CBCT and digital model of maxillary dental arch. (A) Occlusal view. (B) Measurement of bone thickness at the level of left miniscrews. (C) Measurement of bone thickness at the level of right miniscrews.
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The CBCT and the STL files were merged to create an integrated model, and the virtual model of MSE was imported and positioned. The bone thicknesses at the miniscrews insertion sites were measured and found to be less than 2 mm (Figure 13); hence, incorporating 2 additional miniscrews was planned.
Virtual model of bushing and miniscrew utilized for anterior positioning. (A) Lateral view. (B) Anterior view.
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A virtual model of bushing with miniscrew inside was generated with Rhinoceros software (Figure 14).
Positioning of virtual model of additional anterior bushings and miniscrews on the patient integrated model. (A) Occlusal view. (B) 3/4 view. (C) Sagittal section, measurement of bone thickness at the level of additional anterior right miniscrew. (D) Sagittal section, measurement of bone thickness at the level of additional anterior left miniscrew. (E) Finalized MSE appliance.
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It was imported in the patient's integrated model, and positioned anteriorly to the MSE body where bone thickness was higher (Figure 15). The appliance (Figure 15E) was cemented intraorally, and six miniscrews were inserted.