Original Article

Nonsurgical miniscrew-assisted rapid maxillary expansion results in

acceptable stability in young adults
Sung-Hwan Choia; Kyung-Keun Shib; Jung-Yul Chac; Young-Chel Parkd; Kee-Joon Leee

ABSTRACT
Objective: To evaluate the stability of nonsurgical miniscrew-assisted rapid maxillary expansion
(MARME) in young adults with a transverse maxillary deficiency.
Materials and Methods: From a total of 69 adult patients who underwent MARME followed by
orthodontic treatment with a straight-wire appliance, 20 patients (mean age, 20.9 6 2.9 years) with
follow-up records (mean, 30.2 6 13.2 months) after debonding were selected. Posteroanterior
cephalometric records and dental casts were obtained at the initial examination (T0), immediately
after MARME removal (T1), immediately after debonding (T2), and at posttreatment follow-up (T3).
Results: Suture separation was observed in 86.96% of subjects (60/69). An increase in the maxillary
width (J-J; 1.92 mm) accounted for 43.34% of the total expansion with regard to the intermolar width
(IMW) increase (4.43 mm; P , .001) at T2. The amounts of J-J and IMW posttreatment changes
were 20.07 mm (P . .05) and 20.42 mm (P 5 .01), respectively, during retention. The
postexpansion change in middle alveolus width increased with age (P , .05). The postexpansion
change of interpremolar width (IPMW) was positively correlated with the amount of IPMW expansion
(P , .05) but not with IMW. The changes of the clinical crown heights in the maxillary canines, first
premolars, and first molars were not significant at each time point.
Conclusions: Nonsurgical MARME can be a clinically acceptable and stable treatment modality
for young adults with a transverse maxillary deficiency. (Angle Orthod. 0000;00:000–000.)
KEY WORDS: MARME; Transverse maxillary deficiency; Adults; Stability

INTRODUCTION accompanied by unilateral or bilateral posterior cross-

bite or as a conservative nonextraction modality to
Rapid maxillary expansion (RME) is commonly used
increase the arch perimeter and relieve crowding in
to correct transverse maxillary deficiencies that are
adolescents and children.1 However, orthopedic max-
illary expansion using nonsurgical conventional RME
a
Fellow, Department of Orthodontics, Institute of Craniofa- in adult patients has been considered either impossible
cial Deformity, College of Dentistry, Yonsei University, Seoul,
Korea. or rarely successful because the midpalatal suture and
b
Postgraduate student, Department of Orthodontics, College adjacent articulations begin to fuse by late adoles-
of Dentistry, Yonsei University, Seoul, Korea. cence and become more rigid with age.2,3 Potential
c
Associate Professor, Department of Orthodontics, Institute of limitations and side effects of conventional RME in
Craniofacial Deformity, College of Dentistry, Yonsei University,
Seoul, Korea.
adults have been reported, such as expansion failure
d
Professor Emeritus, Department of Orthodontics, College of or limited skeletal expansion, instability of results, pain,
Dentistry, Yonsei University, Seoul, Korea. tissue swelling, buccal crown tipping, gingival reces-
e
Professor, Department of Orthodontics, Institute of Cranio- sion, root resorption, and ulceration.4
facial Deformity, College of Dentistry, Yonsei University, Seoul,
Korea. Surgically assisted RME (SARME) has been fre-
Corresponding author: Dr Kee-Joon Lee, Department of quently used to overcome the above-mentioned limita-
Orthodontics, Institute of Craniofacial Deformity, College of tions through surgical release of the closed sutures that
Dentistry, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, resist expansion forces in adults.5,6 However, patients
Seoul 03722, Korea
(e-mail: [email protected]) tend to be reluctant to undergo multiple surgical
procedures, and the demand for nonsurgical treatment
Accepted: January 2016. Submitted: October 2015.
Published Online: March 3, 2016
has been increasing. Furthermore, surgery is costly and
G 0000 by The EH Angle Education and Research Foundation, requires hospitalization with attendant morbidity, and it
Inc. is challenging in patients with maxillary constriction

DOI: 10.2319/101415-689.1 1 Angle Orthodontist, Vol 00, No 0, 0000

2 CHOI, SHI, CHA, PARK, LEE

combined with severe anteroposterior discrepancies,

because this condition inevitably requires phase 2
surgery.7
Recently, successful maxillary skeletal expansion
with a tooth-bone–borne RME device based on
miniscrews (miniscrew-assisted RME [MARME]) was
introduced7 and is based on previous findings that the
true bony obliteration of the midpalatal suture in
radiographs does not correlate with chronological
age.8–10 Lin et al.11 reported that bone-anchored RME
produced greater orthopedic effects and fewer dentoal-
veolar side effects compared with conventional RME in
late adolescents. Taken together, it appeared crucial to
incorporate bone anchorage to secure the expansion of
the maxillary basal bone. Figure 1. Study flow chart.
To date, most studies on maxillary expansion have
focused on the initial expansion effects in adolescents. a diastema were not observed on periodic periapical
To determine the validity of bone anchorage, the clinical radiographs up to 4 weeks after the initiation of
efficacy and stability in adults following expansion need maxillary expansion (Figure 2). Among the 69 patients,
to be evaluated. To our knowledge, few studies have suture split was not observed in 9 patients; expansion
investigated the success rate, posttreatment stability, was then discontinued, and the treatment plan was
and factors contributing to dental and skeletal post- revised in these subjects.
expansion changes in adults who underwent maxillary Eventually, 20 patients (10 men and 10 women) who
expansion. fulfilled the inclusion criteria were enrolled in the study
The aim of this study was to evaluate the long-term (Table 1). The mean age at the start of expansion was
stability of MARME in young adults with a transverse 20.9 6 2.9 years (range, 18–28 years). The average
maxillary deficiency. We also investigated the success period from the end of expansion to debonding was
rate of MARME in the study population and determined 17.4 6 6.4 months. The mean posttreatment duration
whether treatment changes were correlated with was 30.2 6 13.2 months.
postexpansion changes during retention.
Appliances and Orthodontic Treatment
MATERIALS AND METHODS
All orthodontic treatments were performed by an
Study Design and Subjects orthodontist at the Department of Orthodontics, Yonsei
This retrospective cohort study included 69 young Dental Hospital. As previously described, the MARME
adults with a transverse maxillary deficiency who device is composed of four rigid stainless steel wire
underwent MARME between 2004 and 2010 at the connectors with helical hooks soldered on the base of
Department of Orthodontics, Yonsei Dental Hospital, Hyrax screws (Figure 2).7 Following MARME ce-
Seoul, Korea. The study protocol conformed to the mentation, four miniscrews (diameter, 1.8 mm;
Declaration of Helsinki and was approved by the length, 7.0 mm; self-drilled type, ORLUS, Ortholu-
Institutional Review Board of Yonsei Dental Hospital tion, Seoul, Korea) were inserted perpendicular to
(IRB No. 2-2015-0028). the center of the helical hooks (diameter, 4.0 mm)
The inclusion criteria for this study were as follows: under local infiltration anesthesia. The heads of the
older than 18 years, maxillary constriction with unilateral miniscrews were then attached to the hooks with
or bilateral posterior crossbite, a maxillomandibular light-cured resin (Transbond, 3M Unitec, St Paul,
transverse discrepancy 5 mm greater than the normal Minn) to minimize irritation of the tongue and
value,12 good oral hygiene, healthy periodontal tissues, increase the postinsertion stability of the miniscrews.
no prior history of orthodontic treatment and/or orthog- The MARME device was activated by one-quarter of
nathic surgery, no severe dentofacial anomalies such a turn (0.2 mm) every other day (slow expansion) to
as a cleft lip or palate, requirement for nonextraction minimize tissue damage, pain, and discomfort. The
treatment, and the availability of a complete series of maxillary expansion was discontinued when the
identifiable posteroanterior (PA) cephalograms and maxillary cusp of either maxillary first molar came in
dental casts, including the follow-up records (Figure 1). contact with the corresponding buccal cusp tips of the
Failure of maxillary expansion using MARME was mandibular first molars. After active expansion, the
defined when the midpalatal suture opening and MARME device was maintained for 3 months to allow

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STABILITY OF MARME IN YOUNG ADULTS 3

Figure 2. Fixation of the miniscrew-assisted rapid maxillary expansion (MARME) device and periapical views before and after expansion.
(A) A MARME appliance. (B) Before expansion. (C) After 2 weeks of expansion, a diastema caused by splitting of the midpalatal suture can
be observed.

bone formation in the separated maxillary suture. status of the patients (Table 2; Figure 3). All linear
Subsequently, the patients underwent orthodontic measurements were corrected for magnification using
treatment with a straight-wire appliance. After fixed the scale in each cephalometric film. On the study casts,
orthodontic treatment, removable circumferential re- the width of the maxillary dental arch and the average
tainers were worn at night by all subjects during clinical crown heights were measured. The change in
retention. crown height was used to measure the buccal attach-
ment loss at different time points (T0, T2, and T3).
Measurement Time Points
Dental casts and PA cephalograms (Cranex 3+ Reliability
ceph, Soredex, Helsinki, Finland) were obtained Reproducibility was determined by comparing mea-
before treatment (T0), immediately after MARME surements obtained from original examinations with
removal (T1), immediately after debonding (T2), and those obtained from repeated examinations. All mea-
posttreatment (T3). To minimize positional errors surements were repeated by the same observer after
caused by rotations through the transverse hinge axis, 2 weeks. The method error was calculated by using
the PA cephalograms were obtained in the natural the intraclass correlation coefficient, which was .0.95
head position, with the vertical distance from the for all cephalometric and cast variables measured in
middle point of the ear rod of the X-ray machine to the this study.
exocanthus of the patient being identical at all time
points, as previously described.13
Statistical Analysis
Cast and Cephalometric Analyses All statistical analyses were performed with IBM
SPSS software, version 21.0 (IBM Korea Inc, Seoul,
On the PA cephalograms, nasal cavity width (N-N),
Korea) for Windows. Based on the preliminary study,
maxillary width (J-J), and middle alveolus width (Ma-
a minimum sample size of 10 was required (G*Power
Ma) were digitized by using V-ceph 5.5 (Osstem, Seoul,
3, Dusseldorf, Germany) using a significance level of
Korea) by one observer who was blinded to the clinical
a P value less than .05, a power of 90%, and an effect
Table 1. Characteristics of Subjectsa size of 0.21 to detect differences in skeletal and dental
changes at each time point using a repeated-mea-
Total (N 5 20)
sures analysis of variance (RMANOVA).
Sex The Shapiro–Wilk test was used to verify the
Men 10
Women 10 normality of the data distributions. Descriptive
Age at treatment initiation, year 20.9 6 2.9, (range, 18– statistics, including means and standard deviations,
28) were used to describe each variable analyzed in the
Time from end of expansion to debonding 17.4 6 6.4 study.
(T2–T1, months)
Total treatment duration (T2–T0, months) 21.6 6 6.4 RMANOVA was used to evaluate treatment and
Post-treatment duration (T3–T2, months) 30.2 6 13.2 posttreatment changes over time (T0, T1, T2, and T3).
a
Values are expressed as means 6 standard deviations. T0
Since there were six t tests for skeletal and dental
indicates at the initial examination; T1, immediately after MARME changes, the level of significance was corrected by using
removal; T2, immediately after debonding; T3, at posttreatment. the Bonferroni correction (a 5 .05/6) to prevent type 1 error.

Angle Orthodontist, Vol 00, No 0, 0000

4 CHOI, SHI, CHA, PARK, LEE

Table 2. Definitions of the Parameters Measured in This Study

Parameter Description
Nasal cavity width (N-N) Linear distance (mm) between the left and right points at the lowest part of the
maximum concavity of the piriform rim
Maxillary width (J-J) Linear distance (mm) between the left and right jugula, with jugula defined as the
point on the jugal process at the intersection between the outline of the maxillary
tuberosity and the zygomatic process
Middle alveolus width (Ma-Ma) Linear distance (mm) between the left and right points at the center of the maximum
concavity of the maxillary alveolar bone
Intercanine width (ICW) Linear distance (mm) between the cusp tips of the left and right maxillary canines
Interpremolar width (IPMW) Linear distance (mm) between the mesial fossae of the left and right maxillary first
premolars
Intermolar width (IMW) Linear distance (mm) between the central fossae of the left and right maxillary first
molars
Clinical crown height of the maxillary canine (CH3) Linear distance (mm) of the maxillary canine from the cusp tip to the most apical
point of the gingival margin
Clinical crown height of the maxillary first premolar (CH4) Linear distance (mm) of the maxillary first premolar from the buccal cusp tip to the
most apical point of the gingival margin
Clinical crown height of the maxillary first molar (CH6) Linear distance (mm) of the maxillary first molar from the buccal groove to the most
apical point of the gingival margin

Correlations among treatment (T1–T0) and post- (P , .001; Table 3; Figure 4). The midpalatal suture
expansion changes (T3–T1) and other variables were opened in a triangular shape, with the smallest increase
evaluated by using Pearson correlation coefficient. observed in N-N (1.07 mm) and the largest increase
With regard to the strengths of the correlations, r . .40 observed in intermolar width (IMW; 8.32 mm; Table 4).
indicated a moderate-to-strong correlation, and r , .40 Expansion of IMW was 3.94 times greater than that
indicated a weak correlation. of J-J (2.11 mm).
Immediately after debonding (T2), the change in all
RESULTS skeletal variables was negligible, averaging 20.24 to
20.19 mm (Table 4). However, greater postexpansion
Among the 69 patients, nine (eight men and one change was noted across the first molars (23.89 mm;
woman; mean age, 21.6 6 2.9 years; range, 19–26 P , .001) at T2. An increase in J-J (1.92 mm)
years) exhibited failure of maxillary expansion; there- accounted for 43.34% of the total expansion with regard
fore, the success rate of MARME was 86.96% in this to IMW increase (4.43 mm; P , .001; Figure 5) at T2.
study (Figure 1). After treatment (T3), none of the patients showed
Immediately after MARME removal (T1), all skeletal relapse of the posterior crossbite or edge-to-edge bite.
and dental variables were larger at T1 than at T0 Interpremolar width (IPMW) and IMW were smaller at

Figure 3. Skeletal and dental measurements. (A) N-N, nasal cavity width; J-J, maxillary width; Ma-Ma, middle alveolus width. (B) ICW,
intercanine width; IPMW, interpremolar width; IMW, intermolar width; CH3, clinical crown height of the canine; CH4, clinical crown height of the
first premolar; CH6, clinical crown height of the first molar.

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STABILITY OF MARME IN YOUNG ADULTS 5

Table 3. Mean and Standard Deviation of Skeletal and Dental Variables at Each Time Pointa
Variable T0 T1 T2 T3 P Valueb
Skeletal
N-N, mm 32.79 6 2.011 33.86 6 2.322 33.65 6 2.342 33.58 6 2.392 ,.001
J-J, mm 72.89 6 4.111 75.00 6 4.202 74.82 6 4.072 74.75 6 4.082 ,.001
Ma-Ma, mm 66.69 6 4.891 68.94 6 5.382 68.69 6 5.292 68.64 6 5.282 ,.001
Dental
ICW, mm 33.97 6 1.601 36.83 6 1.593 36.35 6 1.572 36.26 6 1.572 ,.001
IPMW, mm 35.05 6 1.141 41.14 6 1.173 39.21 6 1.192 38.82 6 1.042 ,.001
IMW, mm 46.94 6 3.351 55.26 6 3.214 51.36 6 2.483 50.95 6 2.652 ,.001
a
N-N indicates nasal cavity width; J-J, maxillary width; Ma-Ma, middle alveolus width; ICW, intercanine width; IPMW, interpremolar width;
IMW, intermolar width; T0, at the initial examination; T1, immediately after MARME removal; T2, immediately after debonding; T3, at
posttreatment. Increasing mean values are expressed in ascending numerical order.
b
By repeated-measures analysis of variance with Bonferroni correction.

T3 than at T2, but the amount of decrease in the arch DISCUSSION

width was not clinically significant (approximately 0.4
In using MARME, some clinical factors need to be
mm; Table 4; Figure 5).
considered. The first thing may be the success of
The postexpansion change in Ma-Ma increased
miniscrews in this study. Among the 69 patients,
with increasing age (r 5 2.597; P , .05; Table 5).
5.0% of the miniscrews dislodged during expansion
As the amount of IPMW expansion increased, the and 13.0% showed clinically acceptable mobility
amount of IPMW postexpansion change also increased (Periotest value [Siemens AG, Bensheim, Germany]
(r 5 2.587; P , .05). ,10),14 while the rest remained stable until the
The measurements for the left and right clinical retention period. If suture split was observed, even if
crown heights of each tooth were not significantly one miniscrew at one side failed, the maxillary
different and were pooled. The changes in clinical expansion was continued using the remaining minis-
crown heights of canines (CH3), first premolars (CH4), crews. The second factor is irritation of the maxillary
and first molars (CH6) were not significantly different mucosa by MARME. We can prevent mucosal swelling
at each time point. The amount of gingival recession by accurate placement of the miniscrews and hooks,
was not significant, averaging 0.57 mm to 0.86 mm elaboration of appliance fabrication, and scrupulous
at T3 (Figure 6). oral hygiene maintenance, including copious saline
irrigation followed by gingival massage.
Our study group comprised young adults with a mean
chronological age of 20.9 6 2.9 years at the start of
MARME treatment; the maturation stage was CVMI
stage 6. Midline diastema and radiologic suture opening
were observed in 86.96% of the patients (60/69;
Figure 1). In contrast, nine patients exhibited failure of
suture separation. Variations in suture obliteration and
the resistance from craniofacial structures could be the
reason for expansion failure in adults.7
Both IPMW and IMW increased significantly at T1
and subsequently decreased, following alignment and
comprehensive orthodontic treatment at T2 (Table 4).
Significant increases in N-N (0.86 mm), J-J (1.92 mm),
and Ma-Ma (2.00 mm) accounted for 19.41%, 43.34%,
and 45.15%, respectively, of the total expansion with
regard to IMW (4.43 mm) at T2 (Figure 5). The
measurements accounted for a triangular expansion,
Figure 4. Changes over time after MARME in the skeletal and dental allowing greater buccal displacement of alveolar
measurements. N-N, nasal cavity width; J-J, maxillary width; Ma-Ma, crestal area.15 These results suggest that even a small
middle alveolus width; ICW, intercanine width; IPMW, interpremolar amount of split of the suture (the upper part of the
width; IMW, intermolar width; T0, at the initial examination; T1, triangle) may be crucial to minimize the possible bony
immediately after MARME removal; T2, immediately after debond-
ing; T3, at posttreatment. An asterisk means that there was
dehiscence related to expansion.
a significant difference between each time point and T0. Error bar, The clinical superiority of SARME over nonsurgical
standard deviation. expansion RME has been controversial, possibly

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6 CHOI, SHI, CHA, PARK, LEE

Table 4. Effect of Time on Treatment and Posttreatment Changes After MARME Removala
T1–T0 T2–T0 T3–T0
95% CI 95% CI 95% CI
b b a
Variable Difference Min/Max P Value Difference Min/Max P Value Difference Min/Max P Value
Skeletal
N-N, mm 1.07 0.63/1.51 ,.001 0.86 0.42/1.29 .003 0.79 0.31/1.27 .016
J-J, mm 2.11 1.54/2.68 ,.001 1.92 1.33/2.52 ,.001 1.85 1.26/2.45 ,.001
Ma-Ma, mm 2.24 1.59/2.90 ,.001 2.00 1.37/2.63 ,.001 1.95 1.34/2.57 ,.001
Dental
ICW, mm 2.86 2.07/3.64 ,.001 2.38 1.59/3.16 ,.001 2.29 1.50/3.08 ,.001
IPMW, mm 6.09 5.37/6.81 ,.001 4.16 3.44/4.88 ,.001 3.77 3.14/4.40 ,.001
IMW, mm 8.32 7.27/9.37 ,.001 4.43 3.38/5.48 ,.001 4.01 2.96/5.06 ,.001
a
N-N, nasal cavity width; J-J, maxillary width; Ma-Ma, middle alveolus width; ICW, intercanine width; IPMW, interpremolar width; IMW,
intermolar width; T0, at the initial examination; T1, immediately after MARME removal; T2, immediately after debonding; T3, at posttreatment; CI,
confidence interval; NS, not statistically significant.
b
By repeated-measures analysis of variance with Bonferroni correction.

because of the lack of controlled study, especially in the PA cephalograms were obtained with calibration
adults. Obviously, SARME can secure the basal bone and standardization, projection errors may be unavoid-
expansion in most attempted cases. However, the able. 21 However, scanning voxel size and soft
amount of basal bone expansion and its stability in this tissue condition can also affect the accuracy of the
study can be comparable to those of surgical measurement from cone-beam computed tomogra-
expansion.16 Further controlled studies are required phy images.22 To demonstrate the clinical efficacy
among different treatment modalities. of MARME compared with conventional RME or
There was a significant correlation between the SARME, additional case-controlled studies are
amount of expansion and postexpansion change in the required.
maxillary first premolar region (Table 5). The rigid
structure of RMEs tends to induce parallel expansion CONCLUSIONS
of IMPW and IMW.17,18 As a result, the premolars may
be lingually relocated during alignment according to N Suture separation was observed in 86.96% subjects
arch form. In addition, with increasing age, the amount (60/69) in this study.
of IPMW postexpansion change was large if the N Skeletal changes (about 2 mm) and dental changes
dentoalveolar changes were significant. With age, the (about 4 mm) remained stable during retention.
rigidity of the craniofacial skeleton could limit skeletal N Postexpansion change in the middle alveolus width
effects of MARME.2,3 was correlated with age. The postexpansion change
Handelman reported that the maxillary arch width in IPMW, but not IMW, was positively correlated with
could be maintained after debonding following con- the amount of IPMW expansion.
ventional RME.19 Nevertheless, previous studies have N The clinical crown heights of the maxillary canines,
frequently warned of the risk of gingival recession and/ first premolars, and first molars were not significantly
or bony dehiscence caused by dentoalveolar expan- different during retention.
sion.3,12,20 In contrast, clinical crown heights were not
significantly different in the treatment and posttreat-
ment periods in this study (Figure 6). Gingival re-
cession of , 0.21 mm to 0.52 mm was not clinically
significant during orthodontic treatment with MARME,
which was in accordance with the findings of Lin et al.11
Use of the miniscrew could distribute the stress
throughout the palate, decreasing the concentration
of the stress around the anchor teeth.17
To overcome the retrospective nature of this study,
all attempted cases were collected and followed
regardless of the treatment outcome. In addition,
measurement of the clinical crown height is an indirect
quantification of buccal attachment loss, which does Figure 5. Schematic diagram after MARME. T0, at the initial
not directly reflect hard tissue attachment.19 Although examination; T2, immediately after debonding; T3, at posttreatment.

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STABILITY OF MARME IN YOUNG ADULTS 7

Table 4. Extended

T2–T1 T3–T2
95% CI 95% CI
b b
Difference Min/Max P Value Difference Min/Max P Value

20.21 20.35/20.08 NS 20.07 20.20/0.07 NS

20.19 20.38/0.00 NS 20.07 20.16/0.02 NS
20.24 20.43/20.05 NS 20.05 20.19/0.09 NS

20.48 20.65/20.31 .016 20.09 20.26/0.09 NS

21.93 22.56/21.30 ,.001 20.39 20.67/20.11 NS
23.89 24.94/22.84 ,.001 20.42 20.67/20.17 .01

Table 5. Correlations Among Treatment and Postexpansion Changes and Other Variablesa
Variable
J-J (T3–T1) Ma-Ma (T3–T1) ICW (T3–T1) IPMW (T3–T1) IMW (T3–T1)
Age .250 2.597* .197 .066 .240
Sex .520 .174 2.082 .248 2.206
J-J (T1–T0) 2.491 2.524 .355 .438 .500
Ma-Ma (T1–T0) 2.127 2.169 .073 .027 .000
ICW (T1–T0) 2.473 2.141 .115 2.201 .159
IPMW (T1–T0) 2.227 2.305 .192 2.587* 2.049
IMW (T1–T0) 2.155 2.087 .099 2.118 2.082
a
J-J, maxillary width; Ma-Ma, middle alveolus width; ICW, intercanine width; IPMW, interpremolar width; IMW, intermolar width; T0, at the
initial examination; T1, immediately after MARME removal; T3, at posttreatment. Sex (men, 0; women, 1).
* P , .05.

N The amounts of skeletal and dental postexpansion N These findings suggest that nonsurgical MARME
changes were considered clinically acceptable, can be a clinically acceptable and stable treat-
since none of the subjects presented obvious ment modality for maxillary constriction in young
dental posterior crossbite or edge-to-edge bite, adults.
respectively.
ACKNOWLEDGMENTS
This research was supported by Basic Science Research
Program Through the National Research Foundation of
Korea (NRF) funded by the Ministry of Education, Science and
Technology (2009-0075637).

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