Maxillary skeletal expansion with miniscrew anchorage for adult anterior open bite and nasal obstruction: a case report

Introduction

Posterior crossbites involved in maxillary transverse deficiency are common in daily orthodontic practice. Various treatment modalities for maxillary lateral expansion have been developed and are widely used in clinics. The most common of these is rapid maxillary expansion (RME), which is known as an effective approach for achieving midpalatal suture disarticulation in patients prior to the pubertal growth spurt. However, commonly used RME may result in dental side effects such as gingival recession, alveolar bone strain and resorption, and buccal tilting of the posterior teeth, as well as pain and discomfort (1). Furthermore, RME is unlikely to accomplish true maxillary skeletal expansion in postpubertal patients due to buccal flaring of the maxillary molars (2).

Surgically assisted RME (SARME) can be utilized to treat mature patients with maxillary transverse deficiencies (3-5); however, the following potential for complications should be considered, including alar base flaring, gingival recession, infection, postoperative pain or discomfort, and relapse in the long term (6). In recent decades, the miniscrew-assisted rapid palatal expansion (MARPE) has been developed as a relatively simple, minimally invasive technique for achieving skeletal expansion in adults (7,8). Recently, numerous publications have reported that the maxillary skeletal expander (MSE) effectively corrects maxillary transverse discrepancies with less buccal flare-out of the posterior teeth, improving obstructive sleep apnea (OSA) and enabling functional breathing for mature patients (9,10). Three-dimensional (3D) imaging studies have documented oropharyngeal airway changes following orthopedic/orthodontic interventions, underscoring the value of volumetric assessment for airway evaluation (11,12). This is achieved by applying the force to open the midpalatal and pterygopalatine sutures, thus maximizing the skeletal effect (9,11-13).

We presented the case of an adult patient with an anterior open bite, a posterior crossbite, and a nasal obstruction accompanied by a maxillary transverse deficiency, who was successfully managed using MSE. Furthermore, we evaluated the changes to the airway structure and volume and the respiratory permeability caused by MSE to discuss the feasibility of using MSE to treat a case of skeletal open bite alongside nasal obstruction through hydrodynamic analysis. We present this article in accordance with the CARE reporting checklist (available at https://fomm.amegroups.com/article/view/10.21037/fomm-2025-1-45/rc).

Case presentation

The patient was a 35-year 8-month-old female whose chief complaint was an anterior open bite, anterior crowding, and nasal obstruction. She had no medical history associated with otorhinolaryngology and no history of smoking and sleep problems. She exhibited a convex profile with facial asymmetry (Figure 1A). Gingival recession of the right maxillary canine was observed (Figure 1B). The molar relationships were determined to be Angle Class II on the left and Class I on the right. From the model analysis, the maxillary and mandibular intercanine widths were 32.0 and 26.0 mm, respectively. The coronal arch width at the maxillary first premolars was below −2 standard deviation (SD) (37.0 mm), compared to the Japanese female control (14). The right lateral incisor and the left first premolar showed a crossbite. The overjet was 0.5 mm and the overbite was −2.0 mm. Arch length discrepancies were calculated as −8.0 mm in the maxilla and −4.0 mm in the mandible. Mouth breathing and tongue thrusting were exhibited by the patient due to nasal obstruction from childhood.

Figure 1 Pretreatment records at the age of 35 years and 8 months (April 2020). (A) Facial photographs. (B) Intraoral photographs. (C) Panoramic radiograph. (D) Lateral cephalogram. (E) Lateral cephalometric tracing. (F) Frontal cephalogram. (G) Axial view of CBCT image. (H) Coronal views of CBCT image. These images are published with the patient’s consent. The maxillary bone width was defined as the distance between the right and left bony points at the level of the mesiobuccal root tips of the first molars (H). The nasal wall and floor widths were defined as the distances between the RNW and LNW points and between the RNF and LNF points, as measured in the coronal scan passing through the first upper right molar furcation (H). The maxillary bone width was 53.1 mm, and the widths of the nasal wall and floor were 29.1 and 14.6 mm, respectively. CBCT, cone-beam computed tomography; LNF, left nasal floor; LNW, left nasal wall; LBW, left bony wall; RBW, right bony wall; RNF, right nasal floor; RNW, right nasal wall.

Panoramic radiograph showed that the left maxillary first molar had undergone root canal treatment (Figure 1C). No severe periodontal diseases and temporomandibular disorders were detected. A cephalometric analysis showed a skeletal Class I relationship with a mildly retruded mandible [A-point-nasion-B-point angle (ANB), 4.0°; sella-nasion-A-point angle (SNA), 77.4°; sella-nasion-B-point angle (SNB), 73.4°] (Figure 1D,1E; Table 1) (15). The mandibular plane was steep [Frankfort-mandibular Angle (FMA), 33.0°], indicating a high mandibular plane angle. The maxillary central incisors were lingually tilted [maxillary central incisor axis to Sella-Nasion (U1-SN), 98.1°], while the mandibular central incisors showed a normal inclination [incisor mandibular plane angle (IMPA), 96.4°]. A frontal cephalogram demonstrated minimal or no occlusal cant, although a slight mandibular asymmetry was presented (Figure 1F).

Cone-beam computed tomography (CBCT) was performed using a KaVo 3D eXam (KaVo Planmeca Japan, Tokyo, Japan) with the following acquisition parameters: 120 kV, 5 mA, and 17.4 seconds. The patient’s head was oriented horizontally next to the chin and fixed in place. The images were displayed according to a field of view of 23.0 mm × 17.0 mm and a voxel size of 0.3 mm and evaluated using Invivo^TM version 6 software. Judging by CBCT images, the midpalatal suture was closed (Figure 1G,1H). The volume of the oropharyngeal airway, defined from the palatal plane to the level of the epiglottal apex, was 7,500.0 mm³ and the minimum axial area was 105.0 mm² (Figure 2A-2C), indicating constriction of the upper airway. The coronal CBCT view showed that the right maxillary first molar showed 3.0° of buccal inclination, whereas the contralateral molar showed little or no buccal tilting (Figure 1H). The maxillary bone width was defined as the distance between the right (RBW) and left bony (LBW) points at the level of the mesiobuccal root tips of the first molars (Figure 1H). The nasal wall and floor widths were defined as the distance between the right (RNW) and left nasal wall (LNW) points and between the right (RNF) and left nasal floor (LNF) points, as measured in the coronal scan passing through the first maxillary right molar furcation (Figure 1H). The maxillary bone width was 53.1 mm, and the widths of the nasal wall and floor were 29.1 and 14.6 mm, respectively.

Figure 2 Upper airway analyses using CBCT images at the pretreatment, 3 months after expansion, and at postretention. (A) Measurement of the upper airway volume and the minimum axial area. (B) Hydrodynamic analysis of airflow rate. (C) Nasal cavity volume. The oropharyngeal airway was determined from the palatal plane to the level of the epiglottal apex. CBCT, cone-beam computed tomography.

The patient was diagnosed with an anterior open bite, a maxillary transverse deficiency, dental crowding, and a skeletal Class I jaw-base relationship with a high mandibular plane angle. She had a habit of mouth breathing which may be associated with a nasal obstruction. With this diagnosis, the treatment plan was established as follows (Figure S1).

• 4.0 mm maxillary expansion by MSE to improve the left premolar crossbite.
• Four first premolars extraction to improve tooth crowding.
• Maxillary molars intrusion using miniscrews, followed by counterclockwise rotation of the mandible.

Treatment progress

In August 2020, the MSE (MSE II, Biomaterials Korea Inc., Seoul, South Korea) was connected to bands on the maxillary first molars (Figure 3). Four 1.5 mm diameter, 11.0 mm long miniscrews (Biomaterials mini-implant; Biomaterials Korea Inc.) were inserted into the four slots of the appliance to achieve bicortical engagement (Figure 3A). It was activated twice a day, resulting in a total expansion of 0.27 mm per day, and activation was continued for 16 days. Total expansion of 4.0 mm had been planned; however, 3.0 mm was expanded at the first molars, and 2.5 mm at the canines (Figure 3B). In October 2020, standard 0.018-inch slot brackets (poly Lumière; Tomy International Inc., Tokyo, Japan) were applied to the mandibular teeth and bilateral mandibular first premolars were extracted. Leveling began with a 0.012-inch nickel-titanium archwire. In November 2020, a computed tomography (CT) scan was performed to confirm the disarticulation of the midpalatal suture, and the midpalatal disarticulation was confirmed (Figure 4A,4B). The maxillary bone width increased to 54.3 mm, and the nasal wall and floor widths also increased to 30.5 and 16.5 mm, respectively (Figure 4B). For the oropharyngeal airway, the total volume increased to 116%, and the minimum axial area also increased slightly compared to the pretreatment baseline (Figure 2A-2C). The left premolar crossbite had improved.

Figure 3 Intraoral photographs taken before (A), 2 months (B), and 1 year and 5 months (C) after maxillary lateral expansion.

Figure 4 CBCT images obtained at 3 months after maxillary expansion. (A) Axial view. (B) Coronal views. The maxillary bone width was 54.3 mm, and the nasal wall and floor widths were 30.5 and 16.5 mm, respectively (B). CBCT, cone-beam computed tomography.

In December 2020, standard brackets with 0.018-inch slots were bonded to the maxillary dentition, and bilateral first premolars were extracted in the maxilla. The MSE was completely removed, and two 8.0 mm long miniscrews with 1.4 mm in diameter (Dual-top, Proceed Co., Tokyo, Japan) were buccally placed at bilateral interradicular areas between the maxillary first and second molars to intrude the molars and serve as anchorage. To avoid buccal flare-out of the maxillary molars induced by traction from miniscrews, crown palatal torque was incorporated into the maxillary molar region of the archwire. After leveling, space closure was performed using 0.018×0.024-inch stainless-steel archwires with closing loops (Figure 3C).

In March 2022, detailing with elastics was initiated in both arches. Vertical elastics were used to deepen the anterior bite and oblique elastics were applied to correct the midline deviation. Throughout the orthodontic treatment, myofunctional therapy was adopted to reduce her parafunctional habits including tongue thrusting. In March 2023, all multibracket appliances were removed, and clear retainers were delivered for both arches and instructed to be worn full-time. In addition, a lingually bonded retainer was placed on the mandibular anterior teeth.

Treatment results

The active treatment time, including two months of maxillary expansion with MSE, was 32 months. Posttreatment photographs demonstrated a balanced facial profile (Figure 5A). A Class I canine and molar relationships was achieved. The overjet and overbite were both 2.0 mm (Figure 5B). The maxillary and mandibular dental midlines were matched up to the facial midline. According to the model analysis, the maxillary widths increased by 2.0 mm between the right and left canines, and by 1.5 mm between the right and left first molars. Panoramic radiograph exhibited minimal or no root resorption and adequate root parallelism (Figure 5C). Cephalometric analysis revealed a 1.8° decreased in the FMA, indicating a counterclockwise rotation of the mandible (Figures 5D-5F,6; Table 1). Both the maxillary and mandibular central incisors were lingually inclined, which increased the interincisal angle to 137.5°.

Figure 5 Posttreatment records at the age of 38 years and 8 months (March 2023). (A) Facial photographs. (B) Intraoral photographs. (C) Panoramic radiograph. (D) Lateral cephalogram. (E) Lateral cephalometric tracing. (F) Frontal cephalogram. These images are published with the patient’s consent.

Figure 6 Superimposed cephalometric tracings made before treatment (black; age, 35 years and 8 months), after treatment (red; age, 38 years and 8 months), and after two years of retention (green; age, 40 years and 8 months), on the inner contour of the anterior wall of the sella turcica (A), on the anterior surface of the zygomatic process (B), and on the inner contour of the cortical plate at the lower border of the symphysis.

In March 2025, two years after retention, her facial profile remained favorable. The occlusion was stable with no obvious relapse (Figure 7A,7B). She wore a Hawley-type retainer on her upper and lower dentition only at night. A panoramic radiograph showed proper root parallelism and minimal apical root resorption (Figure 7C). Cephalometric analysis revealed a 0.5° decrease in the FMA compared with the posttreatment value, indicating a counterclockwise rotation of the mandible (Figures 6,7D-7F, Table 1). Model analysis showed little or no relapse in dental arch width at the maxillary canines and at molars when comparing posttreatment and retention. To examine changes in airway volume and maxillary expansion, CBCT was performed. The result showed that the oropharyngeal airway volume remained at 113.0% of the pretreatment value (Figure 7G,7H), while this was 3.0% lower than the volume observed three months after skeletal expansion with MSE. No or minimal apical root resorption was also observed. The patient was also satisfied with the improvement in respiratory function.

Figure 7 Postretention records at the age of 40 years and 8 months (March 2025). (A) Facial photographs. (B) Intraoral photographs. (C) Panoramic radiograph. (D) Lateral cephalogram. (E) Lateral cephalometric tracing. (F) Frontal cephalogram. (G) Axial view of CBCT image. (H) Coronal views of CBCT image. The maxillary bone width was 54.3 mm, and the nasal wall and floor widths were 30.1 and 16.2 mm, respectively (H). CBCT, cone-beam computed tomography. These images are published with the patient’s consent.

Ethical considerations

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

The RME is an effective tool for improving a deficient maxillary arch width. However, the use of RME in adult patients can lead to adverse dentoskeletal effects such as buccal tipping, gingival recession, root resorption, and fenestrations (16,17). With SARME, the posterior crossbite caused by mandibular skeletal deviation can be corrected, leading to profile improvement through bimaxillary surgery (18). Apart from surgical invasion, SARME is the most secure method for skeletal maxillary expansion; however, after a brief informative consultation, the patient rejected the surgical option and accepted MARPE.

MSE is a new dimension in current orthodontics, offering a minimally-invasive orthopedic correction in nongrowing adult patients. A histomorphometric investigation has demonstrated that midpalatal suture closure initiates in the fourth decade of life, with full fusion rarely observed before 25 years of age (19). Even in patients who are not yet pubescent, a minimally-invasive expansion may cause thinning of the buccal alveolar wall (1). Therefore, maxillary transverse expansion in postpubescent patients carries an increased risk and requires a greater degree of bone-borne anchorage than that used in RME. This report describes the use of MSE in a 35.7-year-old patient with an anterior open bite, maxillary transverse deficiency, and nasal obstruction. We achieved 3.0 mm of expansion at the maxillary intermolar width with no or minimal buccal tipping, thus attaining the treatment objective. We have monitored the patient for four and a half years to assess the outcome and long-term stability of the MSE, as well as to evaluate changes in maxillary width and airway volume. Four and a half years after the expansion, maxillary bone width remained stable with 0% relapses. Ploder et al. (20) reported that, on average, 8.6% of patients had a relapse at the intermolar width one year after MARPE in patients with a mean age of 36.1 years. Tang et al. (21) reported that following 12 months of retention, the mean recurrence rate was 5.8% for the nasal width and 19.8% for the lateral pterygoid plate. The present case showed little or no relapse at skeletal and dental width compared with previous reports (20,21).

In this case, an increase in the total volume of the oropharyngeal airway occurred immediately after maxillary lateral expansion with MSE. The case study revealed enlargements of 16.0% in the oropharyngeal airway volume. Furthermore, we performed a hydrodynamic analysis using pre- and post-treatment, and retention CBCT images of airways and demonstrated that the airflow rate improved following maxillary expansion, as visualized through 3D hydrodynamic analysis (Figure 2B,2C). Most previous studies have indicated significant increases in total airway volume after MARPE (22-25). Hur et al. (26) demonstrated that MARPE in an adult OSA patient contributed to enhanced airflow and diminished upper airway resistance. These imply that MARPE successfully enhances the structure of the upper airway, thereby contributing to respiratory function. However, we must be aware that maxillary skeletal expansion does not always yield effective improvements in some patients with OSA (27). Also, we must recognize that the observed increase in airway volume may be the cumulative result of multiple interrelated treatment components: myofunctional therapy; dental decompensation; and maxillary molar intrusion (28,29). These factors likely contributed to mandibular autorotation and subsequent repositioning of the tongue base. Erverdi et al. (30) reported that the anterior open bite was improved mainly through molar intrusion and incisor extrusion, resulting in a clockwise-rotated occlusal plane and a counterclockwise-rotated mandible. In summary, 40.0% of anterior open bite correction was dependent on mandibular autorotation and 60.0% on incisor extrusion (30). In the present case, the anterior open bite improved by 4.0 mm. This was achieved through 1.5 mm of maxillary molar intrusion, 1.0 mm of maxillary and mandibular incisors extrusion, and 1.1° and 1.8° of counterclockwise rotation of the maxillary and mandibular occlusal planes, respectively. Overall, the anterior open bite correction was accomplished through mandibular autorotation in 50.0% of cases and through incisor extrusion in the other 50%.

In this case, gingival recession of the right maxillary canine was observed before treatment, and creeping attachment was anticipated. However, spontaneous improvement of gingival recession was not achieved after correction of tooth crowding in the alveolar bone (31). Gingival grafting should be performed after adequate root positioning in the alveolar bone housing. Since her alveolar bone level has been sufficiently high, periodontal surgery such as an interpositional subepithelial connective tissue graft might be suitable to correct the displaced mucogingival junction and acquire optimal soft tissue thickness (32).

Conclusions

This case report demonstrates the successful treatment of an adult patient with an anterior open bite involved in maxillary transverse deficiency and nasal obstruction using the MSE. Furthermore, during the 2-year retention period, minimal relapse of the anterior open bite and nasal obstruction was noted, resulting in a proper respiratory function. These results suggest that the combined usage of MSE and miniscrews might be an effective treatment for anterior open bite involved in maxillary transverse deficiency in mature patients.

Acknowledgments

The authors wish to thank Tomonori Iwasaki for performing a hydrodynamic analysis of airflow rate using CT data.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://fomm.amegroups.com/article/view/10.21037/fomm-2025-1-45/rc

Peer Review File: Available at https://fomm.amegroups.com/article/view/10.21037/fomm-2025-1-45/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://fomm.amegroups.com/article/view/10.21037/fomm-2025-1-45/coif). E.T. serves as an unpaid editorial board member of Frontiers of Oral and Maxillofacial Medicine from January 2026 to December 2027. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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