Faculty of Dental Medicine (Cairo-Boys)

Department of Orthodontics

Skeletally-Anchored Maxillary Expansion: The Dream of Removing Barriers for Adult

Patients
By
AbdAllah Mohammed Bahaa
MSc(2020G), Demonstrator, Department of Orthodontics,
Al-Azhar University (Cairo, Boys)
Under Supervision of
Prof. Dr. Farouk Ahmed Hussein
Professor & Acting Chairman, Department of Orthodontics,
Faculty of Dental Medicine (Boys-Cairo), Al-Azhar University

Dr. Ramadan Yusuf Abu-Shahba

Associate professor, Department of Orthodontics, Faculty of Dental Medicine
(Boys-Cairo), Al-Azhar University

Dr. Khalid Mohammed Taha

Lecturer, Department of Orthodontics, Faculty of Dental Medicine (Boys-Cairo),
Al-Azhar University
Contents
- Introduction.
- Prevalence among Egyptian population.
Clinical picture
- Diagnostic aids Adult analysis
- Anatomy of the maxillary sutures and limitations to expansion.
- Indications of rapid palatal expansion.
- Introduction of skeletally anchored maxillary expansion.
- Rapid maxillary expansion in adult patients.
- Clinical cases.
- Limitations of skeletally anchored maxillary expansion till 2020.
- Retention and stability after skeletally anchored maxillary expansion.
- Recent advances & recent cases.
 INTRODUCTION
Maxillary transverse deficiency is a problem in
orthodontic patients, creating clinical, esthetic, and
functional problems that may affect both of the
arches.

These problems may include crowding,

impaction and protrusion of the teeth along with the
presence of wide buccal corridors upon smiling.
 Prevalence among Egyptian population

 Maram A.M., studied the prevalence of posterior cross bite in Egyptian adolescent
population in a sample of 5000 Egyptian students who were selected randomly
from different schools in the governments of (Cairo, Giza, Ismaelia, Hurghada,
Sharm al sheikh, Minia).

 It was concluded that, the prevalence of posterior

cross bite in Egyptian adolescent population was
7% with higher incidence in girls than in boys (6:4).

Maram AM. Prevalence of posterior crossbite in Egyptian adolescent population: An epidemiological study. CU Theses. 2012.
 CLINICAL PICTURE
Unilateral or bilateral cross-bite and/or
crowding.

 Transverse dental compensation may mask

the skeletal width deficiency in some cases, in
which, the posterior occlusion may be normal,
but by close inspection a flared maxillary
posterior teeth, palatal cusps below the
occlusal plane with decreased intermolar
width less than 31 mm and accentuated curve
of Wilson may be obvious.
The most common form is a unilateral
presentation with a functional shift of the
mandible toward the crossbite side, which
occurs in 80% to 97% of cases.
 Trnsverse analysis for adult patient
Andrews analysis of six elements
 Element III:
Maxillary transverse deficiency is calculated as the difference between mandibular and maxillary width,
and represents the amount of maxillary skeletal expansion required for the patient as in adult patient it is very
difficult to manipulate the mandibular width without orthognathic surgery.
Maxillary width is defined as the distance between the right and left most concave point on maxillary
vestibule at the level of the mesio-buccal cusp of first molars.
Mandibular width is defined as the distance between the right and left mandibular WALA ridge at the
level of the mesio-buccal groove of first molars.
WALA ridge represents the most prominent portion of the buccal alveolar bone. In a normally developed
maxilla, the maxillary width should be equal to the mandibular width.

Andrews L. The six elements of orofacial harmony. Andrews J. 2000;1:13-22.

CORRECTION
Maxillary transverse deficiency can be corrected by various appliances and
treatment protocols, which usually include maxillary expansion and separation of the
mid-palatal suture.

This includes;
- Rapid Palatal Expansion (RPE)
- Slow Orthodontic Expansion (SOE).
- Micro-implant Assisted Rapid Palatal Expansion (MARPE)
- Surgically Assisted Rapid Palatal Expansion (SARPE).
Anatomy of the maxillary sutures and
limitations to expansion
Circummaxillary
sutures
 All these sutures except intermaxillary, midpalatal and internasal
sutures are nearly parallel to each other and directed from upward
anteriorly to downward posteriorly leading maxillary growth in a
downward and forward direction.

Enlow DH, Hunter WS. A differential analysis of sutural and remodeling growth in the human face. Am J Orthod. 1966;52(11):823-30.
Savara B, Singh I. Norms of size and annual increments of seven anatomical measures of maxillae in boys from three to sixteen years of age.Angle Orthod. 1968;38(2):104-20.
Laowansiri U, Behrents RG, Araujo E, Oliver DR, Buschang PH. Maxillary growth and maturation during infancy and early childhood. Angle Orthod. 2012;83(4):563-71.
 The midpalatal suture
The midpalatal suture represents the fusion of maxillary
palatal processes. It's made up of three segments:

 The anterior segment or intermaxillary segment.

 The middle segment from the incisive foramen to the
transversal suture.
 The posterior segment after the transversal suture.

Ossification of the suture has been considered as a limiting

factor for rapid palatal expansion.

Melsen B. Palatal growth studied on human autopsy material: a histologic microradiographic study. Am J Orthod. 1975;68(1):42-54.
Njio B, Kjær I. The development and morphology of the incisive fissure and the transverse palatine suture in the human fetal palate. Craniofac Genet Develop Bio J.
1993;13(1):24-34.
Persson M, Thilander B. Palatal suture closure in man from 15 to 35 years of age. Am J Orthod. 1977;72(1):42-52.
 Age of suture closure
The timing of palatal suture inter-digitation varies among individuals;

- One study reported that, growth at the midpalatal suture usually ceases between the ages of 13-15 and
in some cases the horizontal growth at the midpalatal suture and apposition may continue until about age 16
in females and 18 in males.

- Other studies indicated that, the timing of the fusion of mid-palatal suture varied greatly with age and
sex. Inter-digitation of mid-palatal suture was noted primarily from 11 to 17 years of age but occasionally found
to occur at older age groups as well.

Some studies showed that some patients had no sign of fusion of the mid-
-
palatal sutures at the age of 32 and 54.
Melsen B. Palatal growth studied on human autopsy material: a histologic microradiographic study. Am J Orthod. 1975;68(1):42-54.
Korbmacher H, Schilling A, Püschel K, Amling M, Kahl-Nieke B. Age-dependent three-dimensional microcomputed tomography analysis of the human midpalatal suture. Orofac Orthoped
Fort Kieferorthop J. 2007;68(5):364-76.
Garrett BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS, Taylor GD. Skeletal effects to the maxilla after rapid maxillary expansion assessed with cone-beam computed tomography.
Am J Orthod Dentofacial Orthop. 2008;134(1):8. e1-8. e11.
35. Kartalian A, Gohl E, Adamian M, Enciso R. Cone-beam computerized tomography evaluation of the maxillary dentoskeletal complex after rapid palatal expansion. Am J Orthod
Dentofacial Orthop. 2010;138(4):486-92.
 Persson et al conducted a study to assess the age at incipient obliteration and the
advancement of closure with age in the intermaxillary and transverse palatal sutures in
order to answer two questions;
 When do the intermaxillary and transverse palatal sutures actually start to be
obliterated?
 How does the degree of obliteration in palatal sutures change with age in young
adults?

They reported that, the midpalatal suture may also obliterate during the juvenile period,
but a marked degree of closure is rarely found until the third decade of life.

Persson M, Thilander B. Palatal suture closure in man from 15 to 35 years of age. Am J Orthod. 1977;72(1):42-52.
CLINICAL SIGNIFICANCE AND REPORTS
 Haas reported that the midpalatal sutures did not separate of
two patients, aged 17 and 19 and only alveolar remodeling and
orthodontic tooth movement were possible in these patients.

 Wertz also found that, older patients exhibited a less skeletal

change. One of his patients, a 16-year-old girl, showed no
midpalatal suture opening after attempted rapid maxillary
expansion.
Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture. Angle Orthod. 1965;35(3):200-17.
Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod. 1970;58(1):41-66.
 Other studies suggested
that, the main resistance to
midpalatal suture opening
is probably not in the suture
itself, but in the surrounding
structures, particularly the
sphenoid and zygomatic
bones.

Isaacson RJ, Ingram AH. Forces produced by rapid maxillary expansion: II. Forces present during treatment. Angle Orthod. 1964;34(4):261-70.
Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapid maxillary expansion: I. Design of the force measuring system. Angle Orthod. 1964;34(4):256-60.
 Effect of the surrounding and
buttressing structures during
expansion
As the maxilla starts to separate, the
zygomatic processes offer some
resistance to expansion, but the system
of sutures allows the expanded
structures to adjust and/or relocate.
Farther posteriorly, the pterygoid plates can
bend only to a limited extent as pressure is
applied to them and their resistance to
bending increases significantly in the parts
closer to the cranial base where the plates
are much more rigid.
Isaacson RJ, Ingram AH. Forces produced by rapid maxillary expansion: II. Forces present during
treatment. Angle Orthod. 1964;34(4):261-70.
Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapid maxillary expansion: I. Design of the
force measuring system. Angle Orthod. 1964;34(4):256-60.
 Indications for RME
 Transverse discrepancy equal to or greater than 4mm.
 Unilateral or bilateral posterior crossbites involving several teeth due to maxillary origin.
 Buccaly inclined maxillary molars to compensate for the transverse skeletal discrepancy.
 Cleft lip and palate patients with collapsed maxillae.
 Elimination of inter-arch tranverse discrepancies prior to orthopedic intervention in Class II
malocclusions.
 Class III malocclusion. The correction of posterior crossbites aids in forward growth of
maxillary base and hence anterior crossbites are also corrected in maxillary deficiency
cases.
 Airway impairment or mouth-breathing tendencies due to maxillary constriction.

Haas AJ. The treatment of maxillary deficiency by opening the midpalatal suture. Angle Orthod. 1965;35(3):200-17.
Wertz RA. Skeletal and dental changes accompanying rapid midpalatal suture opening. Am J Orthod. 1970;58(1):41-66.
Gill D, Naini F, McNally M, Jones A. The management of transverse maxillary deficiency. Dental update. 2004;31(9):516-23.
Agarwal A, Mathur R. Maxillary expansion. Int J Clin Pediatr Dent 2010;3(3):139.
 The following factors need to be considered during treatment planning to determine whether to expand
the dental arches conventionally or with RME:

(A) The magnitude of the discrepancy between the maxillary and mandibular first molar and premolar
widths; if the discrepancy is 4 mm or more, one should consider RME.

(B) The severity of the crossbite, that is, the number of teeth involved.

(C) The initial inclination of the molars and premolars-when the maxillary molars are buccally
inclined, conventional expansion will tip them further into the buccal musculature; and if the mandibular molars
are lingually inclined, the buccal movement to upright them will increase the need to widen the upper arch.
 The undesirable side effects of tooth borne
expanders are:
- Limited skeletal movement (cause questionable effects
on the basal bone after 15 years old).
- dentoalveolar tipping.
- Root resorption.
- Detrimental periodontal consequences.
- Lack of long-term stability.

Gurel HG, Memili B, Erkan M, Sukurica Y. Long-term effects of rapid maxillary expansion followed by fixed appliances. Angle Orthod. 2010;80(1):5-9.
Garib DG, Henriques JFC, Janson G, Freitas MR, Coelho RA. Rapid maxillary expansion—tooth tissue-borne versus tooth-borne expanders: a computed tomography evaluation of
dentoskeletal effects. Angle Orthod. 2005;75(4):548-57.
Introduction of MARPE
In a trial to overcome these limitations, micro-implant-assisted rapid palatal
expansion (MARPE) has recently been introduced.

In the last years, a lot of work has been published on international

literature about maxillary expansion performed with the help of
temporary anchorage devices (TADs).

The main idea is the incorporation of several mini-implants to ensure

expansion of the underlying basal bone and to avoid detrimental effects
on anchoring tooth units.

Lin L, Ahn H-W, Kim S-J, Moon S-C, Kim S-H, Nelson G. Tooth-borne vs bone-borne rapid maxillary expanders in late adolescence. Angle Orthod. 2014;85(2):253-62.
Lin Y. Comparison of skeletal and dental changes with MSE (Maxillary Skeletal Expander) and Hyrax appliance using CBCT imaging: UCLA Thesis; 2015.
 Bone-borne expanders
 MARPE is characterized by a decrease in the
excessive load performed by conventional
appliances on the buccal periodontal ligament of
teeth to which they are anchored, thus resulting in
multiple resorptions on their roots.
 There is also a considerable decrease in accidental
movement of anchoring teeth.
For adolescent patients
Bone-borne expansion has been shown to produce
greater transverse skeletal expansion while
minimizing dental side effects such as dental tipping,
alveolar bending, and vertical alveolar bone loss
compared with tooth-borne RPE appliances.
Lin L, Ahn H-W, Kim S-J, Moon S-C, Kim S-H, Nelson G. Tooth-borne vs bone-borne rapid maxillary expanders in late adolescence. Angle Orthod. 2014;85(2):253-62..
MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W. The effects of micro-implant assisted rapid palatal expansion (MARPE) on the nasomaxillary complex—a finite element
method (FEM) analysis. Prog Orthod. 2014;15(1):52.
Lee K-J, Park Y-C, Park J-Y, Hwang W-S. Miniscrew-assisted nonsurgical palatal expansion before orthognathic surgery for a patient with severe mandibular prognathism. Am J Orthod
Dentofac Orthop. 2010;137(6):830-9.
 Bone-borne palatal expanders have
recently been reported in several
studies to have the ability to correct
transverse maxillary deficiency in
adults, making it a potential
alternative to surgically assisted
RPE.

 Bone-borne expanders have also been

shown to decrease the dento-alveolar
tipping seen in adults when
attempting to use traditional tooth-
borne RPE appliances.
Carlson C, Sung J, McComb RW, Machado AW, Moon W. Microimplant-assisted rapid palatal expansion appliance to orthopedically correct transverse maxillary deficiency in an adult. Am J Orthod
Dentofac Orthop. 2016;149(5):716-28.
Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander,
analyzed with a novel 3D method based on CBCT imaging. Prog Orthod. 2017;18(1):34.
Lagravère MO, Carey J, Heo G, Toogood RW, Major PW. Transverse, vertical, and anteroposterior changes from bone-anchored maxillary expansion vs traditional rapid maxillary expansion: a randomized
clinical trial. Am J Orthod Dentofac Orthop. 2010;137(3):304. e1-. e12.
Garib DG, Navarro R, Francischone CE, Oltramari P. Rapid maxillary expansion using palatal implants. J Clin Orthod. 2008;42(11):665-71.
DEVELOPMENT OF MARPE DESIGN
 (A) The hybrid HYRAX

Wilmes, B.,Nienkemper M., Drescher D. (2010). Application and effectiveness of a mini-implant-and tooth-borne rapid palatal expansion device: the hybrid hyrax. World J
Orthod, 11(4), 323-30.
(B) Hybrid HYRAX with parallel mini-implants

Ludwig B., Baumgaertel, S. Zorkun, B. Bonitz, L. Glasl, B. Wilmes, B. Lisson, J. (2013). Application of a new viscoelastic finite element method model and analysis of
miniscrew-supported hybrid hyrax treatment. American Journal of Orthodontics and Dentofacial Orthopedics, 143(3), 426-435.
 (C) Increasing the number of mini-implants

Park JJ, Park YC, Lee KJ, Cha J, Tahk JH, Choi YJ. Skeletal and dentoalveolar changes after miniscrew-assisted rapid palatal expansion in young adults: A cone-beam computed
tomography study. Kor J Orthod. 2017;47(2):77-86.
 (D) C-expander

Avoiding dental support

Increasing tissue support to

decrease force on implants

Lin, L., Ahn, H. W., Kim, S. J., Moon, S. C., Kim, S. H., & Nelson, G. (2015). Tooth-borne vs bone-borne rapid maxillary expanders in late adolescence. The Angle Orthodontist, 85(2), 253-262.
53- Moon W, Kim J, Ahn W, Kim SH, Kim H, Chung R, & Nelson G. Molar inclination and surrounding alveolar bone change relative to the design of bone-borne maxillary expanders: A CBCT
study. Angle Orthod. 2020; 90(1), 13-22.
 (E) MSE I (Maxillary Skeletal Expander)

parallel 4 mini-implants

Suzuki H, Moon W, Previdente LH, Suzuki SS, Garcez AS, Consolaro A. Miniscrew-assisted rapid palatal expander (MARPE): the quest for pure orthopedic movement. Dental Press J
Orthod. 2016;21(4):17-23.
 MSE II
Parallel 4 mini-implants with bicortical engagement

Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed
with a novel 3D method based on CBCT imaging. Prog Orthod. 2017;18(1):34.
Moon W, Kim J, Ahn W, Kim SH, Kim H, Chung R, & Nelson G. Molar inclination and surrounding alveolar bone change relative to the design of bone-borne maxillary expanders: A CBCT study. Angle
Orthod. 2020; 90(1), 13-22.
Recent MARPE design with arms for
deep palate
It has been a general perception that the predictability of orthopedic expansion is greatly
reduced after 15 years of age due to the higher interdigitation of the midpalatal suture after
puberty.
For adults, RME with a tooth-borne appliance has many adverse effects:
1. Expansion is LIMITED and is only appropriate for DENTAL EXPANSION.
2. The results are UNSTABLE AND RELAPSE is common.
3. PAIN is experienced because of the anatomic resistance to expansion, and because
of ischemia, ulceration, and swelling due to compression of the palatal tissue by the appliance.
4. TIPPING OF THE POSTERIOR TEETH leading to poor occlusion and instability.
5. The maxillary posterior teeth are DISPLACED BUCCALLY THROUGH THE
ALVEOLUS leading to gingival recession, bone loss and root resorption

Some authors affirm that, expansion of the maxilla in post-pubertal patients is not feasible and
surgically assisted rapid palatal expansion (SARPE) is needed.
McNamara JA, Brudon WL. Orthodontic and orthopedic treatment in the mixed dentition: Needham Press; 1993.
Epker BN, Wolford LM. Dentofacial deformities: surgical orthodontic correction: CV Mosby; 1980.
Pogrel M, Kaban L, Vargervik K, Baumrind S. Surgically assisted rapid maxillary expansion in adults. Int J Adult Orthod Orthognath Surg. 1992;7(1):37-41.
Bell WH, Epker BN. Surgical-orthodontic expansion of the maxilla. Am J Orthod. 1976;70(5):517-28.
Betts N, Vanarsdall R, Barber H, Higgins-Barber K, Fonseca R. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthod Orthognath Surg. 1995;10(2):75-96.
 SARPE

 Surgically assisted RPE is an invasive process

that can result in lateral rotation of the 2
maxillary halves with minimal horizontal
translation.

 In addition, surgically assisted RPE may be

detrimental to the periodontium and has
been shown to result in a large amount of
relapse during the post-retention period.

Bell WH, Epker BN. Surgical-orthodontic expansion of the maxilla. Am J Orthod. 1976;70(5):517-28.
66. Betts N, Vanarsdall R, Barber H, Higgins-Barber K, Fonseca R. Diagnosis and treatment of transverse maxillary deficiency. Int J Adult Orthod Orthognath
Surg. 1995;10(2):75-96.
Lehman JJ, Haas AJ, Haas DG. Surgical orthodontic correction of transverse maxillary deficiency: a simplified approach. Plast Reconstruct Surg.
1984;73(1):62-8.
 THE IDEA
 Mini-implant Assisted Rapid Palatal Expanders relies on skeletal anchorage
obtained through mini-implants to directly apply force to the basal bone
without utilizing the dentition as the sole anchorage.
 Due to the increased magnitude of the applied force necessary to split the
interlocking suture in adult patient, a new approach to improve mini-implant
stability during bone-borne expansion is needed.

1.Increase force. (Expansion Protocol)

2.Apply directly to the bone. (Skeletal Anchorage)
3.Increase the stability of mini-implants ??
Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a
novel 3D method based on CBCT imaging. Prog Orthod. 2017;18(1):34.
Suzuki H, Moon W, Previdente LH, Suzuki SS, Garcez AS, Consolaro A. Miniscrew-assisted rapid palatal expander (MARPE): the quest for pure orthopedic movement. Dental Press J Orthod. 2016;21(4):17-23.
 Bi-cortical mini-implant engagement
Bicortical mini-implant anchorage has
been demonstrated in orthodontic tooth
movement applications to be
biomechanically more favorable than
monocortical anchorage.

As such, bicortical anchorage should be

considered for clinical situations requiring
heavy anchorage to improve mini-
implant stability.

Suzuki H, Moon W, Previdente LH, Suzuki SS, Garcez AS, Consolaro A. Miniscrew-assisted rapid palatal expander (MARPE): the quest for pure orthopedic movement. Dental Press J Orthod.
2016;21(4):17-23.
Brettin BT, Grosland NM, Qian F, Southard KA, Stuntz TD, Morgan TA, et al. Bicortical vs monocortical orthodontic skeletal anchorage. Am J Orthod Dentofac Orthop. 2008;134(5):625-35.
Holberg C, Winterhalder P, Rudzki-Janson I, Wichelhaus A. Finite element analysis of mono-and bicortical mini-implant stability. Eur J Orthod. 2013;36(5):550-6.
 A study was conducted in 2017 to evaluate the effects of monocortical and
bicortical mini-implant anchorage on bone-borne palatal expansion.
It was concluded that, bicortical mini-implant anchorage results in improved
mini-implant stability, decreased mini-implant deformation and fracture, more
parallel expansion in the coronal plane, and increased expansion during bone-
borne palatal expansion. However, the depth of bicortical mini-implant
anchorage was not significant.
Lee RJ, Moon W, Hong C. Effects of monocortical and bicortical mini-implant anchorage on bone-borne palatal expansion using finite element analysis. Am J Orthod Dentofac Orthop.
2017;151(5):887-97.
 The beginning……..

Lines in 1975 conducted a study to evaluate the efficacy of rapid

maxillary expansion with corticotomy in adult patients.

The conclusion drawn was that, an expansion of the maxilla can be

attained in nongrowing patients following corticotomy.
 In 2010, Lee et al treated a 20-years-old patient with severe transverse
discrepancy and mandibular prognathism before orthognathic surgery using
an expansion appliance with mini-implants. to avoid another surgery to
approach transverse problem.
The stability of the expansion and the periodontal status were favorable
from the followup clinical and radiologic findings.

Lee K-J, Park Y-C, Park J-Y, Hwang W-S. Miniscrew-assisted nonsurgical palatal expansion before orthognathic surgery for a patient with severe mandibular prognathism. Am J Orthod Dentofac Orthop.
2010;137(6):830-9.
Park et al in 2017 conducted a retrospective study to
evaluate the skeletal and dentoalveolar changes
after mini-implant assisted rapid palatal expansion in
young adults.
The study included 14 patients (mean age, 20.1
years; range, 16–26 years) with maxillary transverse
deficiency treated with MARPE.
They concluded that, MARPE can be an effective
treatment modality for the correction of maxillary
transverse deficiency in young adults through
separation of the midpalatal suture.

Maxillary expansion achieved with MARPE exhibits a

pyramidal pattern.
They found that, the degrees of skeletal, alveolar,
and dental expansion were 37.0%, 22.2%, and 40.7%,
respectively.

Buccal tipping of maxillary teeth upon MARPE leads

to the decrease in buccal alveolar bone thickness
and crestal height.
Cantarella et al. in 2017 conducted a
retrospective study to asses Changes in the
midpalatal and pterygopalatine sutures
induced by microimplant- supported skeletal
expander using CBCT imaging.
The study included 15 patients (6 males, 9 females)
with a mean age of 17.2 ± 4.2 years (range 13.9–26.2
years) who were treated with MSE (Maxillary Skeletal
Expander).

The rate of expansion was two turns (0.25 mm per

turn) per day until inter-incisal diastema appeared
and then, one activation per day was applied.

It was concluded that, MSE efficiently split the

midpalatal suture in late adolescents, and separation
at posterior nasal spine (4.3 mm) was about 90% of
that at anterior nasal spine (4.8 mm), leading to an
almost parallel split of the suture in the sagittal
direction.
 Moon et.al. (2020) conducted a study to
evaluate the molar inclination and
skeletal and alveolar bone changes when
comparing tooth bone-borne (MSE) and
tissue bone-borne type maxillary
expanders (C-expander) using cone-
beam computed tomography (CBCT) in
late adolescence.
They concluded that; The
incorporation of teeth into bone-
borne expanders resulted in an
increase in the severity of side
effects. For patients in late
adolescence, tissue bone-borne
expanders offer comparable
skeletal effects to tooth bone-
borne expanders, with fewer
dentoalveolar side effects.
 A study was conducted to investigate the effects of miniscrew assisted
rapid palatal expansion (MARPE) on changes in airflow in the upper airway
(UA) of an adult patient with obstructive sleep apnea syndrome (OSAS).

Conclusions:
- MARPE improves airflow and decreases resistance in UA.
- It may be an effective treatment modality for adult patients with
moderate OSAS.
 Case 1
Zeinab Mahmoud
18 Years
 Case 2
Donia Ahmed
21 Years
 Case 3
Mohammed Ragab
20 Years
Mohammed Ragab/ 20 Years
 Case 4
Hana Ayman
18 Years

MARPE TTT TOGETHER WITH ORTHODONTIC TTT.

 RETENTION AFTER MARPE TREATMENT
 It was reported that a retention period of at least five
months was necessary to permit adequate
mineralization of the midpalatal suture, in order to
minimize the relapse tendency after rapid maxillary
expansion.
 Others mentioned six months for retention, while
other researches advocated a period of at least
three months.
 Other studies advocated at least 3 month-
retention period to stabilize the expansion by using
MSE appliance in a blocked manner.

- Isaacson RJ, Ingram AH. Forces produced by rapid maxillary expansion: II. Forces present during treatment. Angle Orthod. 1964;34(4):261-70.
- Garib DG, Henriques JFC, Janson G, de Freitas MR, Fernandes AY. Periodontal effects of rapid maxillary expansion with tooth-tissue-borne and tooth-borne expanders:
a computed tomography evaluation. Am J Orthod Dentofac Orthop. 2006;129(6):749-58.
- Ekström C, Henrikson CO, Jensen R. Mineralization in the midpalatal suture after orthodontic expansion. Am J Orthod. 1977;71(4):449-55.
- Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-
supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod. 2017;18(1):34.
 STABILITY

A study was conducted to evaluate the Stability of dental, alveolar,

and skeletal changes after miniscrew-assisted rapid palatal expansion
without surgical intervention in young adults and concluded that; MARPE
can be used as an effective tool for correcting maxillomandibular
transverse discrepancy, showing stable outcomes 1 year after expansion.
LIMITS TILL 2020
 1. Adults with severe anteroposterior and vertical skeletal discrepancies are not good
candidates for RME.
2. Patients with already existing anterior open bite. This is because the RME further opens
the bite and worsen. the condition.
3. RME is contraindicated in patients who are not cooperative with the clinician as the
appliance requires frequent activations
4. Normal buccal occlusion with good interdigitation of cusps and fossa.
5. Molar tipping was inevitable.
6. Limited evidence suggested that MARPE could decrease the loss of the buccal
alveolar bone when compared to conventional RPE.
7. Some authors reported failure of suture opening in adult patient with MARPE.

Lim H-M, Park Y-C, Lee K-J, Kim K-H, Choi YJ. Stability of dental, alveolar, and skeletal changes after miniscrew-assisted rapid palatal expansion. Kor J Orthod. 2017;47(5):313-22.
Copello, F. M., Marañón‐Vásquez, G. A., Brunetto, D. P., Caldas, L. D., Masterson, D., Maia, L. C., & Sant’Anna, E. F. (2020). Is the buccal alveolar bone less affected by mini‐implant
assisted rapid palatal expansion than by conventional rapid palatal expansion. A systematic review and meta‐analysis. Orthod Craniofac Res. 23(3), 237-249.
 Clinical Cases II
With a new concept
and a recent
protocol
There is still lack of strong evidence that supports next slides
It is so recent, only case reports and clinical cases every day all over the world around
us.
No RCTs, yet.
 Case 1
Heidy Tarek
22 Years
 Case 2
Mohammed
Ahmed
19 Years
 Case 3
Waad Waleed
17 Years
Mostafa Anwar
20 Years
Joudy AbdelKader
24 Years
Is it possible to remove
more barriers for adult
patients ??