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Arch Expansion Case Study: Non-Surgical Rapid Palatal Expansion for Facial Asymmetry in a Teen Female

This arch expansion case study features a 15.8-year-old female patient treated at Al Majaz 3, Sharjah, who presented with chin deviation, facial asymmetry, and posterior crossbite caused by a narrow upper jaw. Despite being close to skeletal maturity, timely diagnosis and a CBCT-based assessment of the midpalatal suture allowed us to perform non-surgical rapid palatal expansion (RPE). The patient’s esthetic concerns were addressed through a two-phase orthodontic treatment plan that included skeletal expansion followed by fixed appliance therapy. This approach not only corrected the functional shift and smile asymmetry but also avoided surgery and extractions — all within a 12-month timeframe.

Quick Facts Box (at a glance):

Chief Complaint

“My chin looks off to the left when I close my mouth.”
“My smile looks uneven — one side is too dark.”
“There’s no space for my upper teeth, and I find brushing hard.”

🔍 Clinical Findings

  • Severe crowding in upper anterior teeth

  • Canine crossbite and posterior crossbite on the left side

  • Narrow V-shaped upper jaw with buccal corridor asymmetry

  • Maxillary first molars positioned palatally, contributing to transverse maxillary deficiency and aiding in arch width assessment

  • Facial asymmetry due to functional mandibular shift

  • Chin deviated to the left during closure

  • Smile arc collapsed on left side, exaggerated by arch width deficiency

Case Analysis

This patient presented with a classic case of maxillary transverse deficiency, resulting in:

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  • Functional occlusal shift toward the left

  • Midpalatal suture misalignment

  • Buccal corridor asymmetry and smile imbalance

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The patient also exhibited a transverse skeletal discrepancy contributing to the clinical presentation.

The constricted maxillary arch caused the mandible to shift during closure, mimicking skeletal asymmetry. Diagnosis confirmed that the deviation was functional, not skeletal — opening the door for non-surgical correction through rapid palatal expansion.

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The planned intervention aimed to achieve both skeletal and dental changes to correct the deficiency.

A thorough diagnostic process, potentially involving a dental school-trained specialist, is essential to ensure accurate assessment and optimal treatment planning.

Treatment Challenges & CBCT Evaluation

🔎 Key Challenges:

  • Skeletally mature patient nearing 16 years

  • Midpalatal suture maturity needed verification

  • Aesthetic concerns (female patient) meant surgery should be avoided

  • Buccal corridor, crossbite, and smile arc correction required high precision

📊 Suture Maturity Check:

  • CBCT performed to assess Suture Maturation Index (SMI)

  • Patient classified as Stage C on Angelieri scale
    ✅ Suitable for tooth-borne RME without surgery

Treatment Plan: Two-Phase Protocol

Phase 1: Rapid Palatal Expansion (RPE)

  • Appliance: Banded Hyrax palatal expander with molar tubes

  • Activation: 1 turn AM + 1 turn PM × 14 days

  • Result: 1 mm midline diastema → confirmed midpalatal suture opening

  • Appliance retained passively for 3 months

Phase 2: Fixed Appliances (MBT 0.022)

  • Brackets bonded directly over bands without removing RPE

  • Wire sequence:
    0.014 Cu NiTi → 0.018 Cu NiTi → 0.019×0.025 Cu NiTi → 0.019×0.025 SS

  • RPE removed after 7 months

  • Smile arc refined, canine root torque applied, midline aligned

🗓️ Treatment Timeline

Pre‑ vs Post‑Treatment Gallery

Pre-treatment frontal intraoral photo showing upper anterior crowding and midline deviation

Pre‑treatment Fontal view

  • Constricted upper arch

  • lateral incisor in cross bite

  • lower arch shift towards left side

  • wide buccal corridor space on left side

Post-op frontal intraoral view showing improved smile arc and midline correction after arch expansion treatment

Post‑treatment Fontal view

  • Midline aligned

  • All cross bites corrected

  • Lower arch well aligned with upper arch

  • Right and left buccal corridors spaces are balanced

Right side intraoral view before arch expansion highlighting posterior crossbite and dental interference

Pre - Treatment Right occlusal view

  • Class - I Canine Relationship

  • Class - I Molar Relationship

Right lateral post-op view demonstrating corrected buccal occlusion and ideal canine relationship after rapid palatal expansion

Post - Treatment Right occlusal view

  • Class I Canine Relationship

  • Class I Molar Relationship

  • Ideal occlusal contacts

Left lateral pre-op image showing collapsed buccal corridor and V-shaped maxillary arch

Pre - Treatment left occlusal view

  • Lateral Incisor in crossbite

  • Posterior crossbite at left side occlusion

Left side occlusal view post-arch expansion showing symmetrical molar contacts and expanded upper arch

Post - Treatment left occlusal view

  • Cross bites corrected

  • Class I Canine Relationship

  • Class I Molar Relationship

  • Ideal occlusal contacts

Pre-treatment occlusal view of the upper arch showing narrow palate and crowding

Pre‑treatment maxillary arch

  • Narrow V-shaped upper arch

  • Crowding in the anteriors

  • Constricted at posterior region

Post-treatment upper arch occlusal photograph highlighting broad U-shaped arch form and suture opening

Post‑treatment maxillary arch

  • Expanded upper arch

  • Corrected upper midline

  • Achieved ideal U-Shaped arch form

Lower occlusal view before treatment showing arch form and crowding in the mandibular anterior segment

Pre‑treatment mandibular arch

  • Mild Crowding​

Lower arch post-op view with fixed bonded retainer ensuring long-term stability after orthodontic correction

Post‑treatment mandibular arch

  • Corrected crowding

  • Well aligned lower teeth

  • Achieved ideal arch form

  • Precisely Placed lower fixed retainer

🕤 Before vs After Results

Clinical Outcome Highlights

  • Chin realigned without jaw surgery

  • Posterior crossbite and dental crowding corrected; posterior expansion was achieved to correct the bite

  • Balanced buccal corridors and smile arc achieved

  • Functional mandibular shift resolved

  • Skeletal and dental expansion attained through non-surgical RPE

  • This case demonstrates the effectiveness of orthodontic treatment in resolving complex asymmetry

👨‍⚕️ Doctor’s Summary

“This case underscores how CBCT-based diagnosis and timely rapid maxillary expansion can resolve apparent asymmetry in teens approaching skeletal maturity. By expanding the maxillary arch with a palatal expander, we restored occlusion, symmetry, and patient confidence — all without extractions or surgery.”

Retention Plan

  • Upper retainer worn full-time for 6 months, then nights only

  • Patient educated on hygiene, retainer use, and follow-up schedule

How Skeletal Expansion Solved This Patient’s Arch Deficiency

  • This case involved both dental and skeletal expansion to correct a severe posterior crossbite and maxillary transverse deficiency. Although the patient was approaching adulthood, her skeletally mature condition was still responsive to tooth-borne palatal expansion therapy. The expansion process works by applying force to gradually separate the palatal bones, allowing for effective widening of the upper jaw. Forces were directed to the maxillary teeth near their center of resistance to achieve efficient and controlled expansion. The position of the lingual cusp was carefully evaluated during treatment planning, as it plays a crucial role in assessing arch width and occlusion.

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  • The midpalatal suture showed partial ossification but was successfully opened through rapid palatal expansion, avoiding the need for surgically assisted rapid expansion. In this case, rapid midpalatal suture opening was achieved, facilitating stable skeletal correction.

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  • Our clinical evaluation also confirmed that the upper arch width and symmetry could be enhanced without affecting the mandibular arch, leading to long-term stability and esthetic smile balance.

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  • As the expansion screw activated, the supporting bone responded favorably, promoting natural orthodontic tooth movement and eliminating the need for any surgical procedure or involvement from an oral surgeon.

Additional Insights on Arch Expansion & Breathing Benefits

  • While this patient was treated with rapid palatal expansion, it’s important to note that some cases may benefit from slow expansion, especially in younger patients or when working with tooth tissue borne expanders. There are different types of palate expander devices, including removable, implant-supported, and surgically assisted options, each suited for specific clinical situations. Palate expanders play a significant role in orthodontics by widening the upper jaw, improving bite alignment, and expanding the airway, with benefits for both children and adults. In contrast to the non-surgical approach used here, assisted rapid palatal expansion is a surgical alternative indicated for skeletally mature patients when conventional methods are insufficient. In adult cases with fused sutures or severe discrepancies, surgical expansion may be necessary to achieve the desired maxillary width. Our case required a faster skeletal response.

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  • During expansion, we closely monitored buccal tipping, bone density, and palatal bone response, especially around the maxillary posterior teeth and palatal suture area. We also evaluated arch perimeter, arch length, and overall arch coordination to ensure no negative effects on the mandibular arch or bite opening.

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  • By expanding the narrow upper jaw, we indirectly improved the nasal cavity volume, which often helps in reducing breathing difficulties and early signs of sleep apnea in certain individuals.

Case Treated by:

Dr. Srinivasa Rao Bogavilli
Orthodontist, World Class Orthodontics

Al Majaz 3 - Sharjah

Anytime Dental -Dubai
📞 +971 585963637
 

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