Corticopuncture Facilitated Microimplant-Assisted Rapid Palatal Expansion

Abstract

Introduction: Microimplant-assisted rapid palatal expansion (MARPE) has been considered an alternative to avoid extensive surgical procedures. In order to obtain skeletal results of MARPE, force should be enough to overcome areas of resistance and the first one that is required to be disrupted is the midpalatal suture, which becomes increasingly interdigitated after adolescence.

Objective: The present study aimed at providing a novel approach using a minimally invasive method called corticopuncture (CP) in association with MARPE illustrated by a case report of a 35-year-old Brazilian female Caucasian patient presenting maxillary transverse deficiency.

Method: Treatment plan started with an orthopedic correction of the transverse problem using a MARPE device. After many unsuccessful attempts to activate MARPE, corticopunctures were performed along the midpalatal suture. CP procedure at the midpalatal suture included 8 perforations (2 mm apart), performed after previous predrilling followed by miniscrew insertion (5 mm thread length and 1.8 mm diameter).

Results: After CP and new activation protocol, the opening of the midpalatal suture was observed by CBCT images, showing skeletal results, suture split of 3.14 mm (premolar area) and 2.06 (molar area), an increase of 4.3 mm (premolar) and 3.03 mm (molar) in basal bone width, 4.43 mm (premolar) and 3.1 mm (molar) in cortical bone width, and minimal dental effects (mean of 1.2° of tooth tipping).

Conclusion: The combination of MARPE and corticopuncture method was proved to be a nonsurgical treatment option to correct maxillary transverse deficiency in an adult patient. CP was able to weaken suture interdigitation thus facilitating the split.

Figures

Figure 1

Initial intraoral images: (a) right side, (b) frontal, (c) left side, (d) occlusal view of upper arch, and (e) occlusal view of lower arch.

Figure 2

Lateral X-ray (a). Panoramic X-ray (b).

Figure 3

Ricketts cephalometric and soft and hard tissue integration analyses.

Figure 4

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).

Figure 5

Cone beam CT image of the corticopunctures for an illustration purpose: (a) sagittal view and (b) axial view.

Figure 6

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.

Figure 7

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.

Figure 8

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.

Figure 9

Orthodontic phase of the treatment: (a) frontal, (b) overjet, (c) right, and (d) left.

Figure 10

Final pictures: (a) frontal, (b) overjet, (c) right, (d) left, and (e, f) retention appliance with temporary crowns.

Figure 11

Facial images during smile before, immediately after suture split (presence of the anterior diastema), and after treatment.