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MARPE + Mask by Dr. Jeremy Manuele

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MARPE + Mask

Case studies about a technique that shows promise for growth modification in Class III patients

by Dr. Jeremy Manuele

Over the past few decades, orthodontics has undergone significant transformations because of technological advancements and innovative ideas. However, every innovative idea we see today was once met with skepticism and resistance from the orthodontic community because there was little to no evidence to support it at the time. TADs, surgically facilitated orthodontic therapy and clear aligners are just a few examples.1–4

While this scrutiny is vital to ensure patient safety and allows skilled practitioners to share their knowledge and experience, we must also remain open to new possibilities to keep our specialty moving forward. As time passed and the body of research evidence increased, many of these techniques became widely accepted and adopted by orthodontists worldwide.

Orthodontics and dentofacial orthopedics are constantly evolving fields, and we must continue to embrace new ideas and techniques to advance our specialty. In this article, I will discuss a newer technique—mini-implant-assisted rapid maxillary expansion in conjunction with traditional protraction facemask—that is showing great promise in growth modification for skeletal Class III patients. I will present some case studies to demonstrate the potential benefits of this technique in hopes of sparking further interest and research with this and related treatment modalities.


The challenge
Class III skeletal malocclusions are relatively common, with an incidence rate of approximately 6% of the global population.5 Correcting Class III malocclusions can be a challenge for orthodontists, because the underlying cause can be a small retrognathic maxilla, a prognathic mandible or both. (In Class III patients in American populations, the most common cause is a retrognathic maxilla.6) The growth pattern in these patients is characterized by a greater forward growth of the mandible compared with that of the maxilla, resulting in a more protrusive lower jaw relative to the upper jaw.

This discrepancy in growth leads to an imbalance in the relationship between the upper and lower jaws, resulting in a Class III malocclusion. The treatment of these malocclusions often requires a combination of orthodontic and surgical interventions. However, recent advancements in orthodontic techniques have provided alternative treatment options that can minimize or even eliminate the need for surgery.


A bit of history
Maxillary protraction +/- rapid palatal expansion
Studies have shown that traditional rapid palatal expansion (RPE) and facemask therapy can achieve significant forward movement of the maxilla and improvement in the skeletal Class III malocclusion in growing patients.7 However, the amount of forward movement is related to the age of the patient; in general, the younger the patient, the greater the potential for maxillary advancement via growth modification.

In 2005, Vaughan et al.8 published a randomized controlled clinical trial demonstrating the effectiveness of maxillary protraction with and without maxillary expansion. Participants had a mean age of 7–8 years old and wore a protraction facemask for an average of 14 months (full time in the beginning and 14 hours per day once an end-to-end molar relationship was achieved). Force of elastics was 300–500 g (10–18 ounces) per side. In both groups, A-point moved forward approximately 2.5 mm, with associated counterclockwise rotation of the maxilla and clockwise rotation of the mandible.

Miniplates + maxillary protraction
In 2010, Heymann et al.9 published a pilot study where they used maxillary and mandibular miniplates and intermaxillary traction in six 10- to 13-year-olds. Average treatment time was 12.5 months and the elastic force used started at 150 g (5.3 ounces) per side and progressed up to 250 g (8.8 ounces) per side. They noted an average SNA change of 2 degrees, indicating forward movement of the maxillary complex. They also noted changes at the level of zygoma, which they suggested may be because of the location of the miniscrew placements closer to the zygomaxillary suture.

MARPE + facemask
Maino et al.10 reported on average, the A-point of the maxilla was brought forward 3.4 mm in 28 Class III patients who underwent bone-anchored RPE facemask therapy (ALT-Ramec protocol). Most notable with these changes was that the treatment duration for the protraction was only four months on average with a 14-hour wear time. The elastic force used with the facemask was 400 g (14 ounces) per side.


Case studies
We will now review three cases from my practice of patients who have undergone orthodontic care for Class III malocclusion. To evaluate dental and skeletal alterations (changes), pretreatment, progress and posttreatment CBCT images were obtained using an iCat FLX (Dexis). The field of view covered the mandible, maxilla, upper and lower dentition, and anterior cranial base.

The 3D surface models of the mandible, maxilla, cranial base, and upper and lower dentition were generated using the Segment Editor module in the 3D Slicer software. Image analysis was conducted using Slicer3D with the CMF module software (Maurice Müller Institute) installed.11

The head position of T1 images was adjusted in the coronal and sagittal views using the palatal plane. In the axial, coronal and sagittal views, images were reoriented based on palatal plane reference. Voxel-based registration was employed to superimpose T2 and T1 images. The anterior cranial base, which completes growth by age 7, served as the reference region for 3D segmented anatomical structures. The registration process aimed to achieve the best anatomical fit of the anterior cranial base structures.

The CMF software overlaid 3D surface models registered within the same coordinate system. Closest-point 3D linear distance measurements were taken, and the resulting surface distances were computed and stored as color-coded 3D linear distances.

We utilized the Markups module, a feature in 3D Slicer, to facilitate the creation and management of markups in both 2D and 3D. This allowed us to obtain measurements such as the distance from point A (T1 image) to point A’ (T2 image), as well as the measurement between the right and left maxillary points (Mx Right to Mx Left). A big thanks to Dr. Alexander Plaksin and his team at Imprind Imaging Services for the 3D superimposition workups and data analysis.

Case 1: 8-year, 3-month-old girl, bonded RPE + facemask

This patient presented with concerns of dental crowding and a narrow upper jaw (Figs. 1a–1c). Our treatment plan included a traditional bonded RPE (Fig. 2) and a protraction facemask. She was instructed to turn the RPE once per day for a total of 40 turns (8 mm of expansion at the screw) and to wear the facemask at night with 400 g (14 ounces) force per side. She completed the turns on schedule and wore her facemask for a total of 3.5 months (Figs. 3a–3c)

Her superimpositions (Figs. 4a–4c) show that the transverse skeletal changes (skeletal expansion) was 4.7 mm (2.35 mm per side) and her AP skeletal change was 1.3 mm, which is consistent with the expected changes for the number of turns completed and the amount of time the facemask was worn.
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Case 2: 12-year, 11-month-old boy, maxillary skeletal expander + facemask + full braces

This patient presented with concerns of an underbite (Figs. 5a–5c). Our treatment plan included an MSE anchored with 4 TADs (BioMaterials Korea) connected to bands on the upper 6s, a facemask with arms running from the upper 6 bands, and braces on all erupted teeth (Figs. 6 and 7). The patient was instructed to turn the expander two times per day and to wear the facemask at night with 800 g (28 ounces) of force per side. Additionally, the patient was instructed to wear 6-ounce elastics full time, running from the band hooks on the upper 6s to the hooks on the lower 3s. He completed his turns in six weeks, obtaining approximately 10.5 mm of expansion at the MSE screw (Figs. 8 and 9). He reported being very compliant with the facemask and intraoral elastics (Fig. 9).

His superimpositions (Fig. 10a–10b) show that the transverse skeletal change (skeletal expansion) was 9.8 mm (4.9 mm per side) and his AP skeletal change was 2.9 mm. The amount of dental compensation was significantly less in this case than in the non-TAD-anchored case. The amount of AP change was close to but slightly less than what was reported in the MARPE + facemask research referenced earlier.

[Coronal superimposition videos (Figs. 10c1-3) show the changes that occur within the nasal cavity and sinuses during expansion, which I found to be interesting because this view is not typically evaluated before and after treatment.]
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Fig. 10c1 - Coronal
Fig. 10c2 - Sag
Fig. 10c3 - Axial



Case 3: 43-year, 6-month-old man, custom MARPE expansion appliance + full braces

This patient presented with concerns of spacing, open bite, tooth wear and wanting a dental implant to replace his missing maxillary left lateral incisor (Figs. 11a–c). Our treatment plan included a custom MARPE appliance with eight TADS (Fig. 12a–d), designed by Partners Dental Lab using the patient’s initial CBCT to identify the areas with the most adequate bone for TAD placement, with piezotome palatal midline osteotomy and braces on all the teeth (Figs. 13a–13d).

The patient was instructed to turn the expander two times per day for the first five days, then once per day for 10 days. CBCT images were made before and at his three-week recall visit (the latter to rule out complications, but later used for analysis). At three weeks, the patient’s expansion was not yet complete.

Our intent is to show the skeletal changes in all three dimensions following sutural expansion in an adult male at this earlier time point.

The results of these superimpositions (Figs. 14a and 14b) show a transverse skeletal change of 2.1 mm (1 mm per side) with a transverse dental change at the molars of 5.7 mm (more than 2.5 mm per side). Skeletal AP changes were minimal at this time, however, because the maxilla expands on an arc; it translates downward and forward as skeletal expansion occurs. This resulted in anterior displacement of the maxillary central incisors more than 1 mm and inferior displacement of approximately 0.7 mm, which was enough to correct his anterior edge-to- edge bite.

[Superimposition videos (Figs. 14c1-3) demonstrate how quickly skeletal changes occur with successful split of the maxilla.]
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Fig. 11a
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Fig. 14c1 - Axial
Fig. 14c2 - Coronal
Fig. 14c3 - Sag



Looking forward
The field of orthodontics has witnessed significant advancements in recent years, with expansion techniques taking center stage in the treatment of skeletal Class III malocclusions. However, it is important to acknowledge that these innovative approaches have not come without skepticism and scrutiny. It is crucial for the orthodontic community to remain open-minded and receptive to new ideas. As we continue to invest in research and evidence-based practice, we can better understand the potential of expansion techniques and their impact on treatment outcomes. As evidence continues to emerge, we can look forward to more refined and predictable expansion techniques and indications, leading to improved results and enhanced patient care. By embracing new possibilities and staying committed to learning and growing, we pave the way for a brighter future in orthodontics.

References
1. Papadopoulos MA and Tarawneh F (2007). “The Use of Miniscrew Implants for Temporary Skeletal Anchorage in Orthodontics: A Comprehensive Review.” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontics, 103(5), e6–e15.
2. Moon DG, Lee HS, Im JS and Baek SH (2008). “Factors Associated With the Success Rate of Orthodontic Miniscrews Placed in the Upper and Lower Posterior Buccal Region.” The Angle Orthodontist, 78(1), 101–106.
3. Wilcko T, Bouquot JE and Ferguson, DJ (2001). “Rapid Orthodontics With Alveolar Reshaping: Two Case Reports of Decrowding.” The International Journal of Periodontics & Restorative Dentistry, 21(1), 9–19.
4. Zheng, Liu R, Ni Z, and Yu Z. (2017). “Efficiency, Effectiveness and Treatment Stability of Clear Aligners: A Systematic Review and MetaAnalysis.” Orthodontics & Craniofacial Research, 20(3), 127–133.
5. Alhammadi MS, Halboub E, Fayed MS, Labib A and El-Saaidi C (2018). “Global Distribution of Malocclusion Traits: A Systematic Review.” Dental Press Journal of Orthodontics, 23(6), e1–40.e10.
6. Ngan PW, Deguchi T and Roberts EW (2014). Orthodontic Treatment of Class III Malocclusion. Bentham Science Publishers Ltd.
7. Sar Ç, Arman-Özçrpc A, Uçkan S and Yazc AC (2011). “Comparative Evaluation of Maxillary Protraction With or Without Skeletal Anchorage.” American Journal of Orthodontics and Dentofacial Orthopedics, 139(5), 636–649.
8. Vaughn GA, Mason B, Moon H-B and Turley PK (2005). “The Effects of Maxillary Protraction Therapy With or Without Rapid Palatal Expansion: A Prospective, Randomized Clinical Trial.” American Journal of Orthodontics and Dentofacial Orthopedics, 128(3), 299–309.
9. Heymann GC, Cevidanes L, Cornelis M, De Clerck HJ and Tulloch JFC (2010). “Three-Dimensional Analysis of Maxillary Protraction With Intermaxillary Elastics to Miniplates.” American Journal of Orthodontics and Dentofacial Orthopedics, 137(2), 274–284.
10. Maino, Turci Y, Arreghini A, Paoletto E, Siciliani G and Lombardo L (2018). “Skeletal and Dentoalveolar Effects of Hybrid Rapid Palatal Expansion and Facemask Treatment in Growing Skeletal Class III Patients.” American Journal of Orthodontics and Dentofacial Orthopedics, 153(2), 262–268.
11. Bianchi J. et al. (2020). “3D Slicer Craniomaxillofacial Modules Support Patient-Specific Decision-Making for Personalized Healthcare in Dental Research.” Multimodal Learning for Clinical Decision Support and Clinical Image- Based Procedures. CLIP ML-CDS 2020 2020. Lecture Notes in Computer Science, Vol 12445. Springer, Cham.

Author Bio
Dr. Jeremy Manuele Dr. Jeremy Manuele earned his DMD from the University of Nevada, Las Vegas School of Dental Medicine and his orthodontics certificate from Louisiana State University in New Orleans. He teaches early interventional orthodontics part time at UNLV SDM while maintaining a partner practice with Dr. R. Cree Hamilton in Las Vegas.

Manuele is a key opinion leader and on the clinical advisory board for uLab Systems, provides orthodontic coaching services through Your Ortho Coach, and teaches an online CE course about MARPE 360 for Innovator Ortho. He retired from the Army National Guard after 21 years of service, including an 18-month deployment to Ramadi, Iraq, in 2005–2006. In his free time, he enjoys travel, pickleball and all things outdoors with his wife and their four children.
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