Asymmetry Management During 3D Guided Piezocorticotomy Assisted MARPE Expansion: Case Report

Introduction. Midpalatal suture expansion is effective in both growing and adult patients. Miniscrew-assisted rapid palatal expansion (MARPE) provides greater skeletal effects and fewer dentoalveolar side effects than traditional expanders. However, asymmetric expansion remains a challenge, often influenced by pre-existing craniofacial asymmetries, appliance design, and suture morphology. This case report describes asymmetric expansion using 3D-guided piezocorticotomy-assisted MARPE and its management with direct printed aligners (DPA). Methods. A patient with facial asymmetry, mandibular deviation, narrow maxillary arch, and multiple dentoalveolar deformities underwent pretreatment evaluation, including root inclination analysis and CBCT imaging. A MARPE appliance with 3d guided piezocorticotomy assistance was applied. Post-expansion orthodontic treatment was digitally planned and performed with direct printed aligners. Results. During MARPE activation, asymmetric midpalatal suture disarticulation was observed, with greater displacement on the left side due to jackscrew orientation and root proximity. Post-expansion orthodontic correction with DPAs allowed precise root positioning, redistribution of space, and improved occlusal symmetry. Over 20 months, significant improvements were achieved in midline orientation, axial root inclination, and transverse arch coordination. Conclusion. This case underscores the importance of pretreatment evaluation of asymmetries and careful appliance design in MARPE protocols. It also demonstrates that direct printed aligners, supported by digital planning, can provide accurate and efficient dentoalveolar correction following asymmetric expansion.