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\begin{document}

\title{Non-extraction orthodontic treatment for Class II malocclusion with
severe dental crowding using miniscrew-assisted rapid maxillary
expansion}



\author[1]{Sara Altamash}%
\author[1]{Hasnain Sakrani}%
\author[1]{Naseer Ahmed}%
\author[2]{anand marya}%
\author[3]{Artak Heboyan}%
\affil[1]{Altamash Institute of Dental Medicine}%
\affil[2]{University of Puthisastra}%
\affil[3]{Yerevan State Medical University Named after Mkhitar Heratsi}%


\vspace{-1em}



  
  \date{June 08, 2024}


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\selectlanguage{english}
\begin{abstract}
This case report describes a unique approach in the treatment of a
patient with severe crowding by an orthopaedic widening of the dental
arches using a skeletally anchored rapid palatal expander. This approach
can serve as a robust alternative to extractions and can be effective in
a variety of situations.%
\end{abstract}%



\sloppy


\textbf{Title: Non-extraction orthodontic treatment for Class II
malocclusion with severe dental crowding using miniscrew-assisted rapid
maxillary expansion}

\textbf{Authors:} Sara Altamash\textsuperscript{1}, Hasnain
Sakrani\textsuperscript{2}, Naseer Ahmed\textsuperscript{3}, Anand
Marya\textsuperscript{4}, Artak Heboyan \textsuperscript{5}

Affiliations:

1. Assistant Professor in Orthodontics, Altamash Institute of Dental
Medicine, Pakistan; saraaltamashkhan@yahoo.com

2. Professor, Department of orthodontics, Altamash Institute of Dental
Medicine, Pakistan; sakrani46@gmail.com

3. Associate Professor, Department of Prosthodontics, Altamash Institute
of Dental Medicine, Pakistan; naprosthodontist@gmail.com

4. Department of Orthodontics, Faculty of Dentistry, University of
Puthisastra, Phnom Penh, Cambodia; amarya@puthisastra.edu.kh

5. Department of Prosthodontics, Faculty of Stomatology, Yerevan State
Medical University after Mkhitar Heratsi, Str. Koryun 2, Yerevan 0025,
Armenia; heboyan.artak@gmail.com

Correspondence should be addressed to:

Anand Marya; amarya@puthisastra.edu.kh

\textbf{Abstract}

Malocclusion is caused by an incorrect relationship between the teeth
and jaws, which leads to an abnormal variation of normal occlusion.
Crowding is an increasingly common type of malocclusion caused by a
discrepancy in tooth-jaw size that leads to twisted and misaligned
teeth. Two methods to treat this malalignment are tooth material
reduction and arch width expansion. Of these two treatment options, the
latter is preferred because it enables orthodontists to avoid
extractions and increase the dental arch perimeter by widening the jaws;
this resolves crowding and accommodates existing teeth. This case report
describes a unique approach in the treatment of a patient with severe
crowding by an orthopaedic widening of the dental arches using a
skeletally anchored rapid palatal expander. Under favorable
circumstances, this approach can serve as a robust method to treat
patients with severe crowding and may be used as an alternative to
extraction.

\textbf{Clinical Message:}

Crowding can be corrected by tooth material reduction and arch width
expansion. Expansion enables orthodontists to increase the dental arch
perimeter by widening the jaws; this resolves crowding and helps
accommodate and align existing teeth.

\textbf{Keywords:} severe dental crowding, non-extraction orthodontic
treatment, rapid palatal expansion, miniscrew-assisted rapid maxillary
expansion, rapid palatal expansion with skeletal anchorage

\textbf{Introduction}

Orthodontic treatment aims to achieve facial equilibrium and a balanced
relationship\textsuperscript{1} between teeth and underlying skeletal
structures for all malocclusions, especially in patients with dental
crowding.\textsuperscript{2} Rapid palatal expansion is becoming a
popular treatment option for all patients with crowding because it
allows predictable enhancement of dental arch
perimeter\textsuperscript{3} rather than reduction of tooth
mass.\textsuperscript{4} Miniscrew-assisted rapid maxillary
expansion\textsuperscript{5} is an increasingly popular method for
stable\textsuperscript{6} orthopedic expansion in arch width, especially
in growing patients. Here, we describe an uncommon orthodontic approach
to treating a patient with severe crowding; instead of dental
extraction, treatment comprised increasing arch width and perimeter,
enhanced by using a state-of-the-art miniscrew-assisted rapid palatal
expander.

\textbf{Case History}

A 15-year-old male patient of Asian origin presented for orthodontic
treatment with the chief complaint of crowding in his lower front teeth.
Intraoral clinical examination revealed severe crowding in the mandible,
mild crowding in the maxilla, a bilateral class II canine relationship,
retroclined upper incisors, impinging deep overbite, and overjet of 5
mm. (Figure 1). His convex soft tissue profile and smile analysis
revealed a decreased incisal show (Figure 2).

Lateral cephalometric radiograph analysis showed a mild mandibular
deficiency and high mandibular plane angle, retroclined maxillary
incisors, and proclined mandibular incisors (Figure 3b). Panoramic
radiography showed impacted third molars; rocky mountain analysis on the
posterior-anterior cephalometric radiograph showed a narrow maxilla in
the transverse dimension (Figure 3c).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Skeletal treatment objectives included orthopedic expansion of the
maxilla in the transverse dimension. Dental treatment aimed to increase
intermolar width, upright the mandibular posterior segments
buccolingually, proclining the maxillary incisors, achieve a class I
canine relationship, and position the lower incisors optimally to
achieve ideal overjet and overbite.

Treatment was initiated using a miniscrew-assisted rapid palatal
expander to widen the upper arch by 4 mm (Figure 4). The patient
cooperated with maintaining oral hygiene, and the parents assisted with
turning the expander. After expansion, the molars were banded, and the
remaining teeth were bonded with 0.022'' \selectlanguage{ngerman}× 0.028'' slot standard
edgewise bands and MBT prescription brackets. Initially, both arches
were leveled and aligned through thermo-activated NiTi wires: 0.012''
NiTi, 0.016'' NiTi, and 0.017'' × 0.025'' Nitinol wires. Progress X-rays
and repositioning of bands and brackets were performed as needed to
ensure root parallelism. Arch coordination was then attained with upper
and lower 0.019'' × 0.025'' SS wires. These wires also leveled the Curve
of Spee, uprighted the posterior teeth buccolingually, intruded the
lower anterior teeth, and coordinated the arches. Residual spaces were
closed with power chains, and detailed bends were made. The patient was
debonded after finishing and detailing, and retainers were delivered.
The retainers provided were upper removable wrap-around Hawley and lower
fixed lingual retainers.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

Post-treatment clinical examination showed that crowding was relieved by
a 4 mm increase in the intermolar width of the maxillary and mandibular
arches. Additionally, a class I molar and canine relationship was
achieved with good occlusion (Figure 5) and a pleasing smile (Figure 6).
Post-treatment lateral cephalometric radiographs showed that the
mandible had grown forward in the sagittal dimension, improving the
skeletal profile (Figure 7b). The upper incisors were proclined by 15
degrees to achieve ideal labio-lingual inclination for optimum
aesthetics; the lower incisor was optimally positioned to achieve ideal
overjet and overbite (Figure 7b). Mandibular anterior teeth were
intruded to correct the impinging overbite and level the Curve of Spee.
Finally, the patient was referred to an oral surgeon for extraction of
the third molars.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}

\textbf{Discussion}

Orthodontists must gain a greater awareness that crowding is an
increasingly common type of malocclusion\textsuperscript{2} caused by
abnormalities in the dentition, jaws, or both.\textsuperscript{1} The
severity of this tooth size-arch length discrepancy is typically
measured by visual examination methods and classified as mild, moderate,
or severe crowding.\textsuperscript{7}

Dental\textsuperscript{7} and skeletal\textsuperscript{8} measurements
reveal that crowding is caused by excess tooth size, decreased arch
width, or a combination of large teeth and narrow jaws. Three well-known
treatment options for this type of malalignment in adolescent patients
are interproximal
reduction,\textsuperscript{9}extractions,\textsuperscript{4,} and
expansion.\textsuperscript{2}Interproximal reduction is typically only
used to treat patients with mild-to-moderate crowding, whereas
extraction and expansion are standard treatment options for patients
with all types of crowding. In patients with standard arch width and
excess tooth size, extractions are recommended, especially for those
with severe mandibular crowding (\textgreater{}6 mm).\textsuperscript{4}
In contrast, in the presence of a normal-sized dentition and decreased
arch width, expansion is the treatment of choice because it enables
widening of the dental arches, which predictably increases the arch
perimeter\textsuperscript{3} and provides a given amount of transverse
expansion and accommodates existing teeth. Predicting this relationship
helps promote rapid palatal expanders in patients with crowding; these
expanders facilitate non-extraction orthodontic treatment, which is the
treatment preference for most modern orthodontists.\textsuperscript{10}
In addition, to achieve more significant orthopedic skeletal change,
especially in a growing patient, a miniscrew-assisted rapid maxillary
expander\textsuperscript{5,6} can be used in patients with a true
skeletal transverse discrepancy,\textsuperscript{8} rather than a tooth
tissue-borne rapid palatal expander. Subsequent widening of the dental
arches from this treatment protocol is generally considered
stable,\textsuperscript{6} as it exhibits minimum relapse, especially in
patients with fixed prolonged retention.

In this case report, severe mandibular crowding was caused by a
decreased arch length due to a narrow maxilla (transverse skeletal
discrepancy) that was diagnosed via posterior-anterior cephalometric
radiography: the skeletal width of the maxilla and mandible was measured
based on skeletal landmarks and norms, as developed by
Ricketts.\textsuperscript{8} This decrease in maxillary arch width also
restricted the mandibular arch width, resulting in severe mandibular
crowding and collapsed mandibular posterior segments. Treatment was
initiated with the expansion of the maxillary arch, thereby widening
dental arches and creating an increased arch perimeter; this unraveled
the crowding and allowed uprighting of the collapsed mandibular buccal
segments with routine orthodontic treatment. The key to the alleviation
of crowding in this patient was increasing the transverse dimension by
using a miniscrew-assisted rapid maxillary
expander,\textsuperscript{5,6} rather than a tooth tissue-borne rapid
palatal expander, which enabled a 4 mm increase in the width of the
maxillary dental arch to be achieved by solid orthopedic expansion. The
success of this maxillary expansion increased the mandibular intermolar
width by 4 mm, which created sufficient space to relieve severe crowding
without extraction. In order to ensure the post-treatment long-term
stability of these widened arches, the retention protocol included a
combination of fixed and removable prolonged retention procedures.
Therefore, this case report highlights the importance of increasing the
arch width and arch perimeter\textsuperscript{3} to alleviate dental
crowding during orthodontic treatment, thereby avoiding extractions and
facilitating the maximum preservation of dental units.

\textbf{Conclusion}

In the treatment of patients with severe dental crowding, orthodontists
should critically examine and diagnose the biological basis of the
crowding and address the true cause of the malocclusion; moreover, as an
alternative to orthodontic extractions, orthodontists should consider
treatment techniques that focus on widening dental arch dimensions with
miniscrew-assisted rapid palatal expanders.

\textbf{Conflict of Interest}

The authors declare no conflict of any kind.

\textbf{Consent}

Informed consent was acquired from the patient for the use of his images
and treatment data for research and publication purposes.

\textbf{Data availability}

The authors can provide data related to this manuscript on reasonable
request.

\textbf{Funding}

No funding was acquired or applied for the purpose of this manuscript.

\textbf{Author contributions}

SA, HS, NA- collection of records; SA, AM, AH- analysis and treatment
plan; SA, HS, NA- treatment provision; SA, HS, AM, AH- manuscript
preparation, editing, and revisions. All authors agreed to the final
version of this manuscript for submission.

\textbf{References:}

\begin{enumerate}
\tightlist
\item
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\item
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\item
  Chung DD, Wolfgramm R. Maxillary arch perimeter prediction using
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\item
  Luppanapornlarp S, Johnston Jr LE. The effects of premolar-extraction:
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\item
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\item
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\item
  Little RM. The irregularity index: a quantitative score of mandibular
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\item
  Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engel GA. Orthodontic
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\item
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\item
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\end{enumerate}

\textbf{Figure Legends}

Figure 1: Pretreatment intra-oral photos showing severe mandibular
crowding

Figure 2: Pretreatment extra-oral photos

Figure 3: (a) Pretreatment panoramic radiograph (b) Pretreatment lateral
cephalometric radiograph (c) Pretreatment posterior-anterior
cephalometric radiograph

Figure 4: (a) Mini screws placed for the skeletally anchored rapid
palatal expander

(b) Pre-expansion photo of the skeletally anchored rapid palatal
expander (c) Post-expansion photo of the skeletally anchored rapid
palatal expander

Figure 5: Post-treatment intra-oral photos showing severe mandibular
crowding

Figure 6: Post-treatment extra-oral photos

Figure 7: (a) Post-treatment panoramic radiograph (b) Post-treatment
lateral cephalometric radiograph

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