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Early prevention of malocclusion with use of removable maxillary expander: A clinical case report
*Corresponding author: Mohammad Zeinalddin, Craniofacial Orthodontist, Mohammad Orthodontic Center, Muscat, Sultanate of Oman. dr.mohammad.orthodontics@gmail.com
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Received: ,
Accepted: ,
How to cite this article: AlQarni S, Javanmardi Rahatabad S, Zeinalddin M. Early prevention of malocclusion with use of removable maxillary expander: A clinical case report. J Academy Dent Educ. doi: 10.25259/JADE_13_2025
Abstract
Premature extraction of deciduous teeth without space maintenance can cause malocclusion. This case report describes a 10-year-old female who developed space loss following early extraction of a deciduous molar. Clinical examination and radiography revealed a narrow maxilla and mesially angulated canines. A removable, tooth-borne rapid maxillary expander was used to restore space and maxillary width, guiding eruption and preventing canine impaction. The case demonstrates the benefits of early interceptive orthodontic intervention and highlights the practical value of removable appliances in resource-limited clinical settings.
Keywords
Canine impaction
Case report
Interceptive orthodontics
Mixed dentition
Rapid maxillary expander
INTRODUCTION
Premature loss of deciduous teeth can lead to undesirable space loss due to the mesial drift of adjacent teeth toward the extraction site. This can result in the impaction of permanent successors and subsequent malocclusion. Early orthodontic intervention helps prevent such complications, reducing the need for complex corrective procedures and surgical extractions later in life.
Space maintenance following premature extraction is critical. When space loss has already occurred, functional appliances such as the rapid maxillary expander (RME) can help restore arch width and space for erupting teeth. The RME, whether fixed or removable, has proven effective in managing cross-bites, crowding, and constricted arches during mixed dentition.
Recent studies have shown that early maxillary expansion during the mixed dentition phase may play a preventive role in reducing the incidence of maxillary canine impaction by improving the transverse dimension and eruption pathways.[1,2] The following case report illustrates such an approach in a 10-year-old patient.
CASE REPORT
Patient presentation
A 10-year-old female presented in November 2021 with a complaint of food impaction in tooth 54. Examination revealed that tooth 55 (maxillary right primary second molar) was missing, with nearly complete space closure. Tooth 54 was carious, while tooth 16 was fully erupted and in occlusion. The maxillary arch was U-shaped with posterior constriction; the mandibular arch was ovoid and well aligned. Mild crowding was observed in the maxillary anterior segment. Pretreatment intraoral photographs illustrate these findings [Figure 1].
- Pre-treatment intra oral photographs: (a) Lateral right, (b) frontal, (c) lateral left, (d) upper occlusal.
Radiographic and clinical findings
An orthopantogram showed insufficient space for the eruption of tooth 15, with mesially angulated permanent canines and evidence of maxillary constriction. These findings are demonstrated in pretreatment orthopantogram [Figure 2]. Tooth 54 was restored with glass ionomer cement (Fuji IX GP Extra, GC Corporation, Tokyo, Japan). No formal space or cephalometric analyses were performed initially, as clinical and radiographic findings sufficiently indicated space loss and transverse constriction. The decision prioritized early intervention while minimizing cost and radiation exposure.[3,4]
- Pre-treatment orthopanthogram.
Treatment plan and execution
A removable, tooth-borne RME was fabricated within 1 week of alginate impression taking. The appliance was inserted in April 2022, with instructions to activate once every other day and attend monthly reviews [Figure 3]. The expander was selected over a conventional space regainer to address both space loss and skeletal constriction.[5,6]
- Intra-oral photograph of rapid maxillary expander at the beginning of the treatment.
In August 2022, the appliance fractured and was replaced promptly [Figure 4]. The patient remained highly compliant, attending all follow-up visits. In November 2022, tooth 54 became mobile and was extracted [Figure 5]. The appliance was adjusted accordingly to maintain fit and function.
- Occlusal view of rapid maxillary expander after 4 months of activation.
- Lateral view photograph of tooth 54.
By March 2023, both teeth 15 and 14 showed improved eruption trajectories, and maxillary width was normalized. Following completion of active expansion, the patient underwent mid-treatment radiographic evaluation. Cephalometric and panoramic images demonstrated improved maxillary width and a more favorable angulation of the maxillary canines, indicating a positive response to treatment [Figure 6]. The patient continued part-time (night-only) wear until May 2024, when upper canines began to erupt naturally, marking the end of active treatment [Table 1]. At the conclusion of active therapy, post-treatment radiographs confirmed normalization of the transverse dimension and continued improvement in the eruption pathway of the permanent canines [Figure 7].
| Visit Date | Procedure |
|---|---|
| Nov 2021 | Initial visit; diagnosis and glass ionomer cement restoration of tooth 54 |
| Apr 2022 | Rapid maxillary expander insertion |
| Aug 2022 | Appliance replacement after breakage |
| Nov 2022 | Extraction of tooth 54 |
| Mar 2023 | Orthopantomogram and cephalometric evaluation improved angulation |
| May 2024 | Eruption of canines; end of treatment |
- Mid-treatment (a) lateral cephalogram and (b) orthopantogram.
- Post-treatment (a) lateral cephalogram and (b) orthopantogram.
Final intraoral photographs show improved transverse dental relationships, reflecting the overall success of the interceptive treatment approach [Figure 8].
- Post treatment intra-oral photographs: a) Lateral right, b) lateral left, c) frontal.
Alternative treatment options
Alternative options considered included fixed or removable space regainers, distalization appliances, or early partial fixed orthodontic therapy. However, RME was chosen for its dual skeletal and dental effects, offering arch expansion alongside space recovery.[7]
DISCUSSION
The present case highlights the importance of early interceptive orthodontics in the mixed dentition stage. The use of a removable RME effectively restored arch width and improved canine eruption angulation. Similar studies have confirmed that RME in mixed dentition can prevent canine impaction and enhance long-term arch stability.[1,2,8]
Compared to fixed expanders, removable RMEs are cost-effective, comfortable, and easily adjustable – making them suitable for use in resource-limited environments.[3,4] The success of such appliances depends on patient compliance and consistent follow-up, as demonstrated in this case.
The treatment course also illustrates a balance between clinical judgment and diagnostic economy. While cephalometric and formal space analyses were not performed, radiographic and clinical evidence sufficiently guided treatment decisions without unnecessary radiation exposure.[6,9]
Additionally, the observed space loss and developing malocclusion are consistent with established findings regarding the impact of premature deciduous molar loss on permanent dentition alignment.[10] Despite successful outcomes, this case is limited by its single-patient nature. Further comparative studies across larger populations could strengthen evidence for removable RMEs as early interceptive tools.
CONCLUSION
Early diagnosis and timely intervention in cases of premature deciduous tooth loss can prevent complex orthodontic problems. The use of a removable RME in this case effectively addressed both space loss and maxillary constriction, facilitating the eruption of permanent canines and minimizing future treatment needs. Clinicians should encourage regular dental visits and parental awareness to enable such proactive approaches.
Acknowledgment:
This is to acknowledge that all authors actively participated for preparing this case report.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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