Case Report

Camouflage treatment of skeletal Class III malocclusion with asymmetry

using a bone-borne rapid maxillary expander
Yu-Jin Seoa; Kyu-Rhim Chungb; Seong-Hun Kimc; Gerald Nelsond

ABSTRACT
This case report presents the successful use of palatal mini-implants for rapid maxillary expansion
and mandibular distalization in a skeletal Class III malocclusion. The patient was a 13-year-old girl
with the chief complaint of facial asymmetry and a protruded chin. Camouflage orthodontic
treatment was chosen, acknowledging the possibility of need for orthognathic surgery after
completion of her growth. A bone-borne rapid expander (BBRME) was used to correct the
transverse discrepancy and was then used as indirect anchorage for distalization of the lower
dentition with Class III elastics. As a result, a Class I occlusion with favorable inclination of the
upper teeth was achieved without any adverse effects. The total treatment period was 25 months.
Therefore, BBRME can be considered an alternative treatment in skeletal Class III malocclusion.
(Angle Orthod. 2015;85:322334.)
KEY WORDS: Class III malocclusion; Mini-implant; Rapid maxillary expansion; Asymmetry,
C-expander; Camouflage

INTRODUCTION of orthodontic camouflage treatment or of orthodontic

treatment combined with orthognathic surgery.
Skeletal Class III malocclusion is characterized by
A common strategy of orthodontic camouflage
proclination of the upper incisors and retroclination of
treatment is the use of intermaxillary Class III elastics
the lower incisors to compensate for the sagittal
to correct the sagittal discrepancy.25 Class III elastics
skeletal discrepancy.1 Furthermore, buccal inclination
result in mesial movement of the upper dentition and
of the upper posterior teeth and lingual version of the
distal movement of the lower dentition with proclination
lower posterior teeth are often observed owing to the
of upper and retroclination of the lower dentition.2,58
transverse skeletal discrepancy. In patients with
They also induce extrusion of the upper molars and
severe skeletal discrepancies, orthognathic surgery
lower incisors, resulting in counterclockwise rotation of
after decompensation of the dentition is necessary to
the occlusal plane and an increase in the facial height.5,8
achieve normal occlusion. However, if the skeletal
However, proclined upper incisors and flat smile arcs
discrepancy is mild to moderate, the clinician will seek
are unfavorable esthetic outcomes. The position and
the patients opinion before deciding on a treatment plan
inclination of the upper incisors and the sagittal cant of
a
Clinical Fellow, Department of Orthodontics, Kyung Hee
the occlusal plane are important components of facial
University School of Dentistry, Seoul, South Korea. and smile esthetics.9 To prevent these undesirable
b
Professor and Chairman, Department of Orthodontics, changes, several studies have reported mini-implant
School of Medicine, Ajou University, Suwon, Korea. assisted distalization of the lower dentition.812
c
Associate Professor and Chairman, Department of Ortho- In the camouflage treatment approach, the clinician
dontics, Kyung Hee University School of Dentistry, Seoul, Korea.
will address the sagittal discrepancy and will consider
d
Clinical Professor and Chair, Division of Orthodontics,
Department of Orofacial Science, University of California San nonsurgical maxillary expansion. Tooth-anchored ex-
Francisco, San Francisco, Calif. panders have been conventionally used, but they have
Corresponding author: Dr Seong-Hun Kim, Department of several disadvantages, such as limited skeletal expan-
Orthodontics, Kyung Hee University School of Dentistry, #1 sion, undesirable buccal tipping of the teeth, and buccal
Hoegi-dong, Dongdaemun-gu, Seoul 130-701, Republic of
bone dehiscence.1316 To avoid these adverse effects,
Korea
(e-mail: bravortho@gmail.com) skeletal anchorage for rapid maxillary expansion has
been reported.1719
Accepted: May 2014. Submitted: March 2014.
Published Online: July 17, 2014 This report presents the case of a patient with
G 2015 by The EH Angle Education and Research Foundation, skeletal Class III malocclusion, transverse discrepan-
Inc. cy, and facial asymmetry. The patient was successfully

Angle Orthodontist, Vol 85, No 2, 2015 322 DOI: 10.2319/031314-189.1

CLASS III CORRECTION USING BONE-BORNE RPE 323

Figure 1. Pretreatment facial and intraoral photographs.

treated with a bone-borne rapid maxillary expander Clinical examination showed that she had a prognathic
(BBRME), which was also used as indirect anchorage profile, a relatively long lower face, and facial
for Class III elastics. The purpose of this report is to asymmetry with the chin deviating to the left (Figure 1).
suggest BBRME as an alternative camouflage treat- Intraoral examination revealed a bilateral Class III
ment for Class III malocclusions. molar relationship with a unilateral Class III canine
relationship on the right (Figures 1 and 2). Anterior
Diagnosis and Etiology
edge-to-edge bite and deficient posterior buccal
A 13-year-old girl complained of facial asymmetry, a overjet were associated with anteroposterior positional
protruded chin, and difficulty in occluding her teeth. discrepancy and a protruded mandible but no CO-CR

Figure 2. Pretreatment cast models.

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324 SEO, CHUNG, KIM, NELSON

Figure 3. Pretreatment radiographs: lateral and posteroanterior cephalograms, panoramic radiograph, and hand-wrist radiograph.

discrepancy. The lower posterior teeth were tipped Figure 3; Table 1). Dental compensation was noted
lingually and the upper posterior teeth buccally, with proclined upper incisors (U1 to FH, 126.2u) and
indicating compensation of the transverse discrepan- lingual version lower incisors (IMPA, 84.9u). The
cy. Minor crowding was present in the upper and lower posteroanterior cephalogram showed deviation of the
dentition, with arch length discrepancy of 21.5 mm mandible to the left, with shorter ramus length on the
and 22.5 mm, respectively. left side and the cant of the occlusal plane (Figure 3).
The initial lateral cephalometric analysis showed a The upper dental midline was coincident with the facial
skeletal Class III relationship (ANB, 0.9u) with exces- midline, whereas the lower dental midline was deviat-
sive mandibular growth (Mn body to anterior cranial ed by 2 mm to the left (Figures 1 and 3). There were no
base, 1.2u) and a vertical growth pattern (FMA, 32.3u; other significant findings from the panoramic radiograph,

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CLASS III CORRECTION USING BONE-BORNE RPE 325

Table 1. Lateral Cephalometric Analysis

Variable Mean SD Pretreatment Posttreatment Difference
Sagittal
ANB (u) 3.45 1.87 0.9 2.8 1.9
SNA (u) 81.08 3.73 76.0 76.5 0.4
SNB (u) 78.01 3.81 75.1 73.7 21.4
A point to N-Perp, mm 0.4 2.3 0.5 1.0 0.5
Pog to N-Perp, mm 21.8 4.5 20.5 23.1 22.5
Wits appraisal, mm 22.74 0.3 24.5 23.8 0.7
Mn body to anterior cranial base 1.08 0.03 1.2 1.3 0.1
Vertical
Sum, u 397.16 6.63 406.7 408.8 2.1
Saddle angle, u 125.45 5.32 128.3 128.8 0.4
Articular angle, u 147.68 5.25 149.4 151.6 2.2
Gonial angle, u 124.31 5.36 129.0 128.4 20.6
SN-FH, u 14.5 14.5 0.0
FH-Palatal plane angle, u 1.2 4.72 24.9 24.9 0.1
FH to Occl plane angle, u 29.63 5.66 7.5 10.3 2.8
FH to mandibular plane angle, u 29.63 5.66 32.3 34.4 2.1
Facial height ratio (posterior/anterior) 65.3 8.75 59.0 58.0 21.0
ANS-Me/Nasion-Me 0.55 0.02 0.6 0.6 0.0
Dental
U1-FH, u 113.8 6.37 126.2 115.6 210.6
U1 to SN, u 105.28 6.64 111.8 101.2 210.6
IMPA, u 91.62 5.23 84.9 76.6 28.3
Overbite, mm 2.5 1 20.5 2.0 2.5
Overjet, mm 2.5 1 1.5 4.1 2.6
U6 to palatal plane, u 106.0 106.0 0.0
L6 to mandibular plane, u 103.0 109.5 6.5
Soft tissue
Upper lip to E-line, mm 0.86 2.36 20.1 20.1 20.1
Lower lip to E-line, mm 5.87 2.93 0.9 0.9 0.0

except for the developing third molars. Residual growth assuming an upright position of the compensated
was expected to some extent, because the hand-wrist posterior teeth, the transverse discrepancy disap-
radiograph demonstrated MP3-G or SMI 7-8 (Figure 3) peared, indicating a normal transverse relationship.
and the patients menarche had begun a year ago. The Camouflage treatment was an alternative, consider-
patient was diagnosed with skeletal Class III malocclu- ing the mild anteroposterior discrepancy, the extent of
sion, with transverse discrepancy and facial asymmetry. malocclusion, and the patients facial profile. The
sagittal and midline discrepancies can be improved
Treatment Objectives by orthodontic treatment, assuming non-extraction and
asymmetric distalization of the lower dentition. How-
The treatment objectives were to (1) establish a
ever, expansion of the maxilla is necessary not only to
proper occlusion, (2) resolve the transverse discrep-
correct the transverse discrepancy but also to increase
ancy, (3) improve inclination of the compensated teeth,
the arch perimeter, thus allowing reduction of the
(4) correct the midline discrepancy, (5) maintain
crowding. If the maxillary suture is patent, expansion
periodontal health, and (6) establish an esthetic profile.
can be achieved by a variety of methods in adolescent
Furthermore, the jaw growth needed to be monitored
patients. The characteristics and design of the
constantly.
expander need to be considered carefully. In this
case, the design should be such that the expander
Treatment Alternatives
does not hinder tooth movement, since camouflage
Orthognathic surgery after growth completion can be treatment with a full fixed orthodontic appliance is
the first treatment option because of the anteroposterior planned, aside from the maxillary expansion. Further-
jaw relationship and facial asymmetry. In this approach, more, growth observation is essential, because resid-
vertical facial height can also be improved with impaction ual growth is expected to some extent.
of the maxilla and reduction genioplasty. When posi- After considering all the alternatives, the patients
tioning the casts to a Class I molar relationship and family chose camouflage orthodontic treatment, as

Angle Orthodontist, Vol 85, No 2, 2015

326 SEO, CHUNG, KIM, NELSON

Figure 4. C-expander for maxillary expansion and its utilization for indirect skeletal anchorage for tooth movement. (A) Maxillary expansion was
successfully achieved. Note the spaces in the anterior region. (B) While holding the expander for stability of expansion, leveling and alignment
can also be achieved. (C) The upper first molars were connected to the expander for indirect absolute anchorage against Class III elastics. Mesh
pads were bonded on the upper first molars, and the wires soldered to mesh pad were connected to C-expander using acrylic resin. (D) Multiloop
edgewise archwire with tip-back bend in the lower dentition.

they did not want orthognathic surgery. They were and aligning, the lower third molars were extracted. A
informed that orthognathic surgery could be recom- 0.019 3 0.025-inch stainless-steel archwire was en-
mended after growth completion. gaged in the upper dentition, and a 0.016 3 0.022-inch
stainless-steel multiloop edgewise archwire with tip-
Treatment Progress back bend was engaged in the lower dentition. Class
III elastics (5/16-inch, 4 oz) were used for distalization
Initial treatment was started with maxillary expan-
of the lower dentition for 5 months bilaterally and
sion. The C-expander, which is a BBRME appliance,
another 6 months unilaterally on the right side. The
consists of three parts: four mini-implants (1.8-mm
upper molars were reinforced by connecting the upper
diameter, 8.5-mm length; C-implant Co., Seoul,
first molars to the C-expander to prevent the mesial
Korea), an expansion screw, and an acrylic body.
movement of the upper dentition or extrusion of the
Four mini-implants were placed on the palatal slope
molars by the Class III elastics. This indirect anchor-
8 mm apical to the alveolar ridge: two between the
age acted as an absolute anchor via the mini-implants
canines and first premolars and the other two between
within the C-expander. Other elastics were applied
the second premolars and first molars. An acrylic resin
with different vectors and forces on each side, to
body with an expansion screw was fabricated on the
achieve midline correction and interdigitation. The C-
cast model, along the curvature of the hard palate.
expander and the mini-implants were removed at
After installation of the mini-implants, the fabricated
completion of treatment, after debonding. For reten-
acrylic body was connected to the mini-implants by
tion, lingual fixed retainers were bonded on the upper
adding acrylic resin. The expansion screw (Foresta- and lower incisors, and circumferential removable
dent Co, Pforzheim, Germany) was turned once a day retainers were used in both arches. The patient was
(0.25 mm/d), and the process was terminated at advised to practice a tongue posture to contact the
6 weeks. Separation of the midpalatal suture was palatal surface.
assessed clinically by the development of the median
diastema (Figure 4) and also through cone-beam TREATMENT RESULTS
computed tomograms and radiographs (Figures 5
and 6; Table 2). The total duration of treatment was 25 months. A
After a 6-week consolidation period, the upper and Class I occlusion with proper interdigitation, overbite,
lower fixed appliances were bonded while holding the and overjet was achieved (Figures 7 and 8). The upper
C-expander for stability of expansion. After leveling and lower dental midline coincided with the facial

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CLASS III CORRECTION USING BONE-BORNE RPE 327

Figure 5. Images of cone-beam computed tomograms taken before and after the bone-borne maxillary expansion. Palatal suture was separated
and expanded with minimal tipping of the teeth and the alveolar bone. The added lines were used for measuring the inclination of the teeth (nasal
floor and axis of the palatal root). (A) At the upper first molar. (B) At the upper second premolar (left, before expansion; right, after expansion).

midline. The patient developed a straight profile, and and lower molars might have resulted from the
the facial asymmetry improved (Figures 7 and 9). compensatory alveolar growth. Soft tissue changes
Although the lower facial height remained elongated, accompanied the skeletal and dental changes.
the patient and her parents were satisfied with the Sufficient maxillary expansion with minimal tipping of
facial profile and occlusion that was achieved without the segment was achieved through the C-expander,
orthognathic surgery. resulting in an average 5.08-mm increase in trans-
Superimposition of the lateral cephalometric tracings verse width, with only 0.98u buccal tilting of the
before and after treatment showed that the mandible posterior teeth and 1.98u buccal tilting of the alveolar
rotated clockwise (FH to mandibular plane angle, from bone (Figure 5; Table 2). The inclination of the upper
32.3u to 34.4u) owing to vertical growth, and the ANB dentition was corrected, and it remained within the
angle increased from 0.9u to 2.8u (Figures 9 and 10; normal range at completion of treatment (Figures 7
Table 1) with retrusion of the chin, resulting in a and 8). The maxillary arch width, before and after
straight profile. The upper incisors were retroclined into treatment, showed minimal changes at the level of the
normal inclination (U1 to FH, from 126.2u to 115.6u). cusp tip but greatly changed at the level of the dental
The lower incisors were retracted and retroclined along cervical margin (Figures 2, 8, and 11; Table 3). This
with the extrusion (IMPA, from 84.9u to 76.6u), and the implies that the uprighting of the upper canines and
lower molars were tipped backward with mandibular posterior teeth was achieved through skeletal expan-
distalization, thus establishing a positive overbite and sion and the subsequent recovering lingual inclination.
overjet. With respect to the vertical growth of both During treatment, the patient did not complain of
jaws, as shown in Figure 10, extrusion of the upper discomfort. There were no complications, such as

Angle Orthodontist, Vol 85, No 2, 2015

328 SEO, CHUNG, KIM, NELSON

Figure 6. Midtreatment radiographs after maxillary expansion: lateral and posteroanterior cephalograms, panoramic radiograph.

inflammation of the palatal soft tissue, that were DISCUSSION

induced by the appliance. Although local gingival The conventional method of Class III camouflage
swelling was observed on the buccal side of the treatment usually includes Class III elastics.2,58 How-
posterior teeth during debonding, this was related to ever, Class III elastics aggravate the already proclined
poor oral hygiene around the brackets and not to the upper incisors and extrude the upper molars, resulting
expander itself. At the 9-month posttreatment follow- in an unesthetic smile and unintended clockwise
up, the gingival swelling had resolved, and stable rotation of the mandible.9 To avoid this, several studies
occlusion had been maintained (Figure 12). have reported mini-implantassisted distalization of

Angle Orthodontist, Vol 85, No 2, 2015

CLASS III CORRECTION USING BONE-BORNE RPE 329

The reference line was tangent to the nasal floor at its most inferior level, as seen in Figure 6. Inclination of the alveolar bone was measured by the angle between the reference line and
Expansion Difference Expansion Expansion Difference
the lower dentition.812 The advantage of this method is

3.76

4.63

5.47

5.74

4.90
At the Level of Root Apex
its ability to tip the lower molars distally with intrusion
and the lower incisors lingually with extrusion, while
avoiding any movement of the upper dentition.812 Mini-

43.03

39.03

41.45

37.34
implants can be installed in the posterior area of the
After
maxilla or the mandible, with a goal to cancel or avoid
the vertical force vector of the Class III elastics. In the
Transverse Width, mm

case of maxillary mini-implants, Class III elastics are

Before

39.27

34.40

35.98

31.60
applied from this skeletal anchorage instead of the
upper molars.8,10,12 As for mini-implants in the mandi-
ble, Class I elastics (elastic chain or Ni-Ti coil spring)
are applied.9,11,12
4.44

4.90

5.05

5.93

5.08
Transverse maxillary deficiency can be treated with
nonsurgical expansion such as tooth-borne or tooth-
At the Level of Center of

and-tissue-borne expansion in adolescent and young

53.24

50.60

46.55

40.91
After

adult patients.2022 However, the expanding force

Pulp Chamber

the tangent of the palatal slope, and inclination of the teeth, by the angle between the reference line and the axis of the palatal root.
applied through the teeth has been reported to
contribute to adverse effects such as limited skeletal
Expansion

effect, undesirable tooth tipping, bony dehiscence,

Before

48.80

45.70

41.50

34.98

gingival recession, root resorption, and relapse.1316,23

To overcome these adverse effects, BBRME with
skeletal anchorage has been reported.1719 The major
Difference
0.50
0.20
0.30
1.10
1.40
1.40
3.90
21.00
0.98

advantage of BBRME is that it provides maximum

Inclination of the Teeth, u

skeletal and minimum dental effects, since the

expansion forces can be directly applied to the basal
bone and not to the teeth.18,19 However, a previous
Expansion
118.50
118.10
109.40
114.40

112.50

105.40
98.30

89.60
After

study using finite element analysis reported that the

treatment effects differed, depending on the type of
Table 2. Changes Before and After Bone-Borne Maxillary Expansion in the Coronal Viewa

expander and position of the mini-implants.19 There-

Expansion

fore, the design of the appliance is critical to the

96.90

85.70
118.00
117.90
109.10
113.30

111.10

106.40
Before

achievement of the desired effect.

In this case, it was reasonable to use maxillary
skeletal anchors for the Class III elastics instead of
Difference

mandibular mini-implants, since the treatment plan

Inclination of the Alveolar Bone, u

1.50
0.80
3.10
1.70
2.80
5.10
0.40
0.40
1.98

called for both bone-borne rapid maxillary expansion

and distalization of the lower dentition. Considering
these factors, the C-expander with palatal mini-
Expansion

implants was selected for BBRME. Mini-implants were

103.10
102.50
105.50
114.00
113.20
125.00

115.20
88.70
After

first used for maxillary expansion and then used as an

indirect anchorage for the distalization of the lower
dentition, without additional installation of mandibular
Expansion

88.30
101.60
101.70
102.40
112.30
110.40
119.90

114.80
Before

mini-implants. As a result of the maxillary expansion,

the transverse discrepancy was corrected and the
upper dentition was aligned without further proclination
of the teeth. The lower dentition was distalized by
Right

Right

Right

Right
Left

Left

Left

Left

Class III elastics without further proclination of the

upper incisors.
The C-expander, as observed in this case as well as
Upper second premolar

other previous studies, has several advantages in

Upper second molar

Upper first premolar

orthodontic treatment:
Upper first molar

N Mini-implants on the palatal slopes demonstrate the

least stress concentration around the anchorage and
Mean

a relatively parallel alveolar expansion, compared

a

with other BBRME.19

Angle Orthodontist, Vol 85, No 2, 2015

330 SEO, CHUNG, KIM, NELSON

Figure 7. Posttreatment facial and intraoral photographs.

Figure 8. Posttreatment cast models.

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CLASS III CORRECTION USING BONE-BORNE RPE 331

Figure 9. Posttreatment radiographs after maxillary expansion: lateral and posteroanterior cephalograms, panoramic radiograph.

N The expander itself can be used for retention after C-expander appliance that is supported by mini-
completing expansion, without necessitating the implants.
transpalatal arch or removable appliances that con- N Oral hygiene is better since they permit brushing and
ventional protocol demands. flossing of all teeth as opposed to tooth-borne
N The teeth can be aligned and leveled simultaneously expanders.18
using the fixed appliance because this expander does
not contact any teeth.18 This combined method of BBRME with modified
N Indirect absolute anchorage can be provided Class III elastics using indirect anchorage achieved a
by connecting the desired anchor tooth to the Class I relationship and a favorable facial profile

Angle Orthodontist, Vol 85, No 2, 2015

332 SEO, CHUNG, KIM, NELSON

Figure 10. Superimpositions of lateral cephalograms (solid line: pretreatment; dotted line: posttreatment).

without orthognathic surgery, just as the patient and have contributed to the successful result of the
her parents had desired. Furthermore, the acceptable orthodontic camouflage treatment. Nevertheless, while
amount and direction of growth in this patient might treating adolescent patients with the camouflage
method, residual growth should be constantly moni-
tored, considering the possibility of worsening of the
mandibular prognathism or facial asymmetry. Regular
follow-up is also needed for long-term stability.

CONCLUSIONS
N This case report demonstrates that BBRME and
distalization of the lower dentition using palatal mini-
implants can be effective in the treatment method of
a moderate skeletal Class III malocclusion.
N BBRME can provide expansion with more skeletal
effect and minimal dental tipping, thus improving the
inclination of the posterior teeth.
N The use of Class III elastics against indirect
anchorage resulted in distalization of the lower
dentition, while avoiding unfavorable mesialization
of the upper dentition or molar extrusion. Therefore,
Figure 11. Superimpositions of computed tomography surface scan BBRME can be considered an alternative in the
image (dark gray color: pretreatment; light gray color: posttreatment). camouflage treatment of Class III malocclusion.

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CLASS III CORRECTION USING BONE-BORNE RPE 333

Table 3. Changes in the Maxillary Arch Width (mm) of Cast Models Before and After Treatmenta
At the Level of Cusp Tip At the Level of Cervical Point
Width Pretreatment Posttreatment Difference Pretreatment Posttreatment Difference
Upper canine 33.92 35.45 1.53 24.30 28.16 3.86
Upper first premolar 44.26 44.33 0.07 27.06 31.73 4.67
Upper second premolar 48.81 50.83 2.02 33.08 36.11 3.03
Upper first molar 55.87 55.72 20.15 38.46 38.85 0.39
Upper second molar 61.08 61.09 0.01 44.80 45.32 0.52
a
The reference point was the cusp tip for the upper canine, the buccal cusp tip for the premolar, and the mesiobuccal cusp tip for the upper
molar. The reference point for the cervical point was the most bulging cervical point on the palatal surface of the tooth.

Figure 12. Follow-up facial and intraoral photographs, 9 months after debonding.

ACKNOWLEDGMENT 6. Troy BA, Shanker S, Fields HW, Vig K, Johnston W.

Comparison of incisor inclination in patients with Class III
This work was supported by the National Research Founda- malocclusion treated with orthognathic surgery or orthodon-
tion of Korea (NRF), funded by the Korean government (MEST; tic camouflage. Am J Orthod Dentofacial Orthop. 2009;135:
No. 2012R1A5A2051388). 146.e19.
7. Burns NR, Musich DR, Martin C, Razmus T, Gunel E, Ngan
REFERENCES P. Class III camouflage treatment: what are the limits?
Am J Orthod Dentofacial Orthop. 2010;137:9.e113.
1. Jacobson A, Evans WG, Preston CB, Sadowsky PL. 8. He S, Gao J, Wamalwa P, Wang Y, Zou S, Chen S.
Mandibular prognathism. Am J Orthod. 1974;66:140171. Camouflage treatment of skeletal Class III malocclusion with
2. Lin J, Gu Y. Preliminary investigation of nonsurgical multiloop edgewise arch wire and modified Class III elastics
treatment of severe skeletal Class III malocclusion in the by maxillary mini-implant anchorage. Angle Orthod. 2013;
permanent dentition. Angle Orthod. 2003;73:401410. 83:630640.
3. Janson G, de Souza JE, Alves Fde A, et al. Extreme 9. Jing Y, Han X, Guo Y, Li J, Bai D. Nonsurgical correction of
dentoalveolar compensation in the treatment of Class III a Class III malocclusion in an adult by miniscrew-assisted
malocclusion. Am J Orthod Dentofacial Orthop. 2005;128: mandibular dentition distalization. Am J Orthod Dentofacial
787794. Orthop. 2013;143:877887.
4. Moullas AT, Palomo JM, Gass JR, Amberman BD, White J, 10. Chung K, Kim SH, Kook Y. C-orthodontic microimplant for
Gustovich D. Nonsurgical treatment of a patient with a Class distalization of mandibular dentition in Class III correction.
III malocclusion. Am J Orthod Dentofacial Orthop. 2006;129: Angle Orthod. 2005;75:119128.
S111S118. 11. Chung KR, Kim SH, Choo H, Kook YA, Cope JB.
5. Hu H, Chen J, Guo J, et al. Distalization of the mandibular Distalization of the mandibular dentition with mini-implants
dentition of an adult with a skeletal Class III malocclusion. to correct a Class III malocclusion with a midline deviation.
Am J Orthod Dentofacial Orthop. 2012;142:854862. Am J Orthod Dentofacial Orthop. 2010;137:135146.

Angle Orthodontist, Vol 85, No 2, 2015

334 SEO, CHUNG, KIM, NELSON

12. Baek SH, Yang IH, Kim KW, Ahn HW. Treatment of Class III maxillary expansion: a randomized clinical trial. Am J Orthod
malocclusion using miniplate and mini-implant anchorage. Dentofacial Orthop. 2010;137:304.e112.
Semin Orthod. 2011;17:98107. 18. Lee KJ, Park YC, Park JY, Hwang WS. Miniscrew-assisted
13. Smalley WM, Shapiro PA, Hohl TH, Kokich VG, Branemark nonsurgical maxillary expansion before orthognathic surgery
PI. Osseointegrated titanium implants for maxillofacial for a patient with severe mandibular prognathism. Am J
protraction in monkeys. Am J Orthod Dentofacial Orthop. Orthod Dentofacial Orthop. 2010;137:830839.
1988;94:285295. 19. Lee HK, Bayome M, Ahn CS, et al. Stress distribution and
14. Garib DG, Henriques JF, Janson G, de Freitas MR, displacement by different bone-borne palatal expanders
Fernandes AY. Periodontal effects of rapid maxillary with micro-implants: a three-dimensional finite-element
expansion with tooth-tissue-borne and tooth-borne expand- analysis [published online November 11, 2012]. Eur J
ers: a computed tomography evaluation. Am J Orthod Orthod. doi:10.1093/ejo/cjs063.
Dentofacial Orthop. 2006;129:749758. 20. Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical
15. Brunetto M, Andriani Jda S, Ribeiro GL, Locks A, Correa M, rapid maxillary expansion in adults: report on 47 cases using
Correa LR. Three-dimensional assessment of buccal the Haas expander. Angle Orthod. 2000;70:129144.
alveolar bone after rapid and slow maxillary expansion: a 21. Stuart DA, Wiltshire WA. Rapid palatal expansion in the
clinical trial study. Am J Orthod Dentofacial Orthop. 2013; young adult: time for a paradigm shift? J Can Dent Assoc.
143:633644. 2003;69:374377.
16. Pangrazio-Kulbersh V, Jezdimir B, de Deus Haughey M, 22. Baysal A, Uysal T, Veli I, Ozer T, Karadede I, Hekimoglu S.
Kulbersh R, Wine P, Kaczynski R. CBCT assessment of Evaluation of alveolar bone loss following rapid maxillary
alveolar buccal bone level after RME. Angle Orthod. 2013; expansion using cone-beam computed tomography. Korean
83:110116. J Orthod. 2013;43:8395.
17. Lagrave`re MO, Carey J, Heo G, Toogood RW, Major PW. 23. Lione R, Franchi L, Cozza P. Does rapid maxillary
Transverse, vertical, and anteroposterior changes from expansion induce adverse effects in growing subjects?
bone-anchored maxillary expansion vs traditional rapid Angle Orthod. 2013;83:172182.

Angle Orthodontist, Vol 85, No 2, 2015