PMC8497132_01
PMC8497132_02
Initial lateral cephalogram.
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fig1
The cephalometric analysis (Figure 1 and Table 1, carried out using Delta-Dent software, outside format, Spino d'Adda, Italy) brought to light the third-class skeletal malocclusion (AN/Pog-5 ) brachyfacial (SN/Go-Gn: 28.7 ;
Initial intraoral photographs.
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fig2
At a dental level (Figure 2), the patient presented a first-class molar rapport and a canine with upper incisor positioned normally, an important retro inclination of the lower incisors (-1/Go-Gn: 80 ) and an increase in the interincisor angle (144.4 ). Aesthetically (Figure 3), the patient had a good profile with a minor increase of the nasolabial angle although a slight protrusion of the chin was noticeable given the anatomy of the mandibular symphysis.
Initial extraoral photographs.
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fig3
At a dental level (Figure 2), the patient presented a first-class molar rapport and a canine with upper incisor positioned normally, an important retro inclination of the lower incisors (-1/Go-Gn: 80 ) and an increase in the interincisor angle (144.4 ). Aesthetically (Figure 3), the patient had a good profile with a minor increase of the nasolabial angle although a slight protrusion of the chin was noticeable given the anatomy of the mandibular symphysis.
Initial OPT.
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fig4
The initial OPT did not show any relevant problems (Figure 4).
CBCT suture evaluation.
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fig5
PMC8497132_03
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Implants digital planning.
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fig6
The protocol makes use of a superimposition of Standard Triangulation Language (STL), obtained in this case from the scan of the initial impression and superimposed on the Digital Imaging and Communication in Medicine (DICOM) obtained from the CBTC using the specific Easy Driver  software (Figure 6).
Operative sequence.
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fig7
Tochigi, 322-8666, Japan) set at 20 rpm and 25 N/cm torque using the free-drill method without any need for irrigation (Figures 7 and 8). In a separate sitting, the appliance was cemented to the first upper molars using GIC:glass ionomer cement (Ketak Cem, 3M, Maplewood, Minnesota, USA), and following this, it was anchored, using specific tightening screws, onto the TADs. The expansion procedure included 4 turns of the screws immediately after this (0.8 mm) followed by 2 turns every day (=0.4 mm) for a total of 23 days.
Implants and hybrid RME placed.
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fig8
Tochigi, 322-8666, Japan) set at 20 rpm and 25 N/cm torque using the free-drill method without any need for irrigation (Figures 7 and 8). In a separate sitting, the appliance was cemented to the first upper molars using GIC:glass ionomer cement (Ketak Cem, 3M, Maplewood, Minnesota, USA), and following this, it was anchored, using specific tightening screws, onto the TADs. The expansion procedure included 4 turns of the screws immediately after this (0.8 mm) followed by 2 turns every day (=0.4 mm) for a total of 23 days.
Before expansion treatment.
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fig9
Fifteen days after the initial activation, a check-up X-ray was taken to assess the opening of the suture (Figure 9).