case_images: PMC6305058_01
case_images: Initial intraoral images: (a) right side, (b) frontal, (c) left side, (d) occlusal view of upper arch, and (e) occlusal view of lower arch.
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case_images: fig1
case_images: 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).
case_images: Lateral X-ray (a). Panoramic X-ray (b).
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case_images: fig2
case_images: Lateral and panoramic x-rays show good inclination of upper incisors, lower incisors slightly proclined, and absence of all third molars (Figure 2).
case_images: Ricketts cephalometric and soft and hard tissue integration analyses.
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case_images: fig3
case_images: Lip sealing was presented (Figure 3).
case_images: 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).
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case_images: fig4
case_images: 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)).
case_images: Cone beam CT image of the corticopunctures for an illustration purpose: (a) sagittal view and (b) axial view.
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case_images: fig5
case_images: In the anterior part of the palate perforations were done carefully in order to avoid the nasopalatine canal (Figure 5).
case_images: 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.
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case_images: fig6
case_images: 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.
case_images: 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.
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case_images: fig7
case_images: A diastema between incisors was then observed (Figure 7).
case_images: 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.
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case_images: fig8
case_images: 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).
case_images: Orthodontic phase of the treatment: (a) frontal, (b) overjet, (c) right, and (d) left.
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case_images: fig9
case_images: Final pictures: (a) frontal, (b) overjet, (c) right, (d) left, and (e, f) retention appliance with temporary crowns.
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case_images: fig10
case_images: Since spaces were prepared for rehabilitation, the patient was referred to implantology and prosthodontics (Figure 10).
case_images: Facial images during smile before, immediately after suture split (presence of the anterior diastema), and after treatment.
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case_images: fig11
case_images: 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).