Hsu et al.

BMC Oral Health (2023) 23:887 BMC Oral Health

https://doi.org/10.1186/s12903-023-03589-5

CASE REPORT Open Access

Digital workflow for mini‑implant–assisted

rapid palatal expander fabrication–a case report
Li‑Fang Hsu1,2, Won Moon3,4, Shih‑Chin Chen5 and Kelvin Wen‑Chung Chang6*

Abstract
Background Non-surgical mini-implant assisted rapid palatal expansion, or midfacial skeletal expansion, is a para‑
digm-shifting concept that in recent years has expanded the envelope of orthopedic movement in the transverse
direction for adult patients. Although adding mini-screws to a rapid palatal expander is not complicated, accurate
and successful expansion strongly depends on the device’s position and its relation to the resisting structures
of the maxillofacial complex.
Case presentation This article presents a digital workflow to locate the optimal position of the Midfacial Skeletal
Expander (MSE) device in a CBCT-combined intraoral scan file and describes how to transfer the MSE position intra-
orally with properly sized bands during the device fabrication. The complete digital workflow of MSE fabrication
and its application for a Class III orthognathic surgical case is presented in detail.
Conclusions This report describes a completely digital process that can accurately position the MSE device accord‑
ing to the orientation and morphology of maxillary basal bone, which is crucial in adult cases demand maxillary
expansion.
Keywords MSE, MARPE, Maxillary expansion, Digital workflow

Background expanders, such as the Schwarz expander [5, 6]. RPE’s

Rapid palatal expansion (RPE) is an effective approach treatment effects have also been thoroughly investigated
for treating constricted maxilla or transverse deficiency [7–9]. Depending on varying degrees of mid-palatal
in children and young adolescents. It was first described sutural interdigitation and resistance from other peri-
more than 100 years ago as a tooth-borne device and maxillary sutures, maxillary basal bone expansion (skel-
then further developed in diverse forms: banded and etal component) accounted for only 20%–50% of the total
bonded maxillary expanders [1–4], as well as removable expansion, for both a Haas type of expander and other
types of RPE [10, 11]. Furthermore, the expansion results
*Correspondence: have a substantial degree of relapse, so an overcorrection
Kelvin Wen‑Chung Chang and a long retention period for bone consolidation are
[email protected] critical with the traditional tooth-borne RPE appliances
1
Department of Dentistry, National Taiwan University Hospital, Hsinchu
Branch, Hsinchu, Taiwan [11–14].
2
Graduate Institute of Clinical Dentistry, School of Dentistry, National The concept of mini-screw–assisted rapid pala-
Taiwan University, Taipei, Taiwan tal expansion/ midfacial skeletal expansion (MARPE/
3
The Forsyth Institute, Cambridge, MA, USA
4
Ajou University School of Medicine, Suwon‑si, Korea MSE) emerged more than a decade ago [15–18]. In the
5
Section of Orthodontics, School of Dentistry, Center for Health Science, MARPE/MSE designs, mini-screws substitute teeth as
University of California, Los Angeles, CA, USA the main anchorage receiving the expansion force and
6
Breeze Dental Center, No. 588, Xianzheng 2Nd Rd., Zhubei City, Hsinchu
County, Taiwan (R.O.C.) transfer the force to the underlying skeletal structures
and hold the positions of the two expanded maxillary

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Hsu et al. BMC Oral Health (2023) 23:887 Page 2 of 13

halves during the bony bridging of the two segments. overlooked anatomical factors such as a skewed maxillary
After a skeletal expansion, the compensated teeth can suture or canted palatal vault, can produce unsatisfactory
be decompensated and aligned into a more physiologi- expansion results [24, 27]. On the other hand, if mini-
cal position. The reported basal bone expansion results screws on a single side fail due to inadequate position-
of various MARPE designs range from 40%–95% in adult ing, then the appliance will become tooth-borne on the
patients [18–20]. This wide range in skeletal components failed-screw side. This will result in a detrimental effect
can be attributed to various MARPE designs that pro- on the banded first molar on that side and often leads to
duce different results. Some are true bone-borne devices, the expansion failure.
but some are hybrid devices with significant tooth move- To tackle this problem, recent publications have intro-
ment. The MSE has two banded teeth incorporated in duced digitally aided design processes [28–30]. Can-
its design to stabilize the jackscrew position during the tarella et al. used commercially available software to
expansion, but the arms attaching the bands to the jack- establish an optimal MSE position first and then printed
screw are a soft alloy and the expansion force transferred out the position guide for soldering on a stone model
to the anchor teeth is minimal. The force vector and mag- [28]. Giudice et al. used Dolphin software to import a
nitude generated by each MARPE also affect the pattern negative MSE template to position the expander and the
and quality of expansion. When MARPE is used properly, mini-screws, then printed the maxillary model combined
it can produce a breakthrough result in regard to both with a negative MSE template for soldering [29]. These
patient age and treatment efficacy. two methods demonstrated the concept of virtual mini-
However, the MARPE method is technique-sensitive, screw placement. However, both approaches still require
and the position of the mini-screws can have a signifi- a band selection and pick-up impression appointment
cant effect on the success rate and the pattern of expan- since bands are still needed to generate the stone model
sion of such devices. Maxillary bone thickness [21] and for soldering. Hence, the process is not fully digital.
the surrounding anatomical structures should be care- This article aims to describe a complete digital solution,
fully examined before mini-screw placement. Before from mini-screw positioning to accurate molar band
deciding on which MARPE to use, one must consider the selection, using a combination of various commercial
two competing concepts: bone-driven system vs. resist- software for Midfacial skeletal expander II (MSE II, Bio-
ance-driven system. The bone-driven system favors the Materials Korea, Korea). The digital workflow is further
position of the min-implant to be in the area of a large demonstrated in a case report of a Class III orthognathic
bony mass for stability, usually in the anterior palate. surgical case.
This placement generates an anterior force vector which
produces a “V-shaped” expansion with limited posterior Digital workflow
skeletal expansion [22, 23]. MSE is a resistance-driven Software
system in which the force vectors are generated directly Autodesk Meshmixer (Autodesk Inc., San Rafael, CA,
against the resisting structures, which are mostly in the USA), 3Shape Implant Studio (3Shape, Copenhagen,
posterior region. The posterior force vector is necessary Denmark), 3Shape Dental System (3Shape, Copenhagen,
for achieving a parallel expansion with a good split of the Denmark).
posterior nasal spine [24]. However, the posterior palatal
bone is thinner than the anterior region, and the mini- Prepared materials
implants must be placed immediately lateral to the mid- Digital model of the upper arch, cone beam computed
palatal suture where the bone density and volume are tomography (CBCT) image of the maxilla, MSE screw
greater [25]. A bicortical engagement of mini-implants in the STL file (acquired by reverse engineering), MSE
is an essential part of MSE placement, to maximize the II expander in the STL file (obtained from the desktop
skeletal component of expansion and to reduce implant scanner) (Fig. 1).
failure [26]. Overlooking the mini-implant position may
result in negative sequelae, such as penetration of the Operation procedures
mini-screw across the mid-palatal suture, engaging the Step 1. Preliminary placement of the MSE
septal structure, monocortical engagement, tilting of All the information in STL format can be imported and
the devices, and irritation of the inferior nasal conchae. moved freely in the open-sourced Autodesk Meshmixer
Li’s research examined whether bi-cortical engagement software. The MSE expander and four screws are prelimi-
or anteroposterior positioning of the MSE affected the narily placed according to the anatomical structures and
success rate and found that both bi-cortical engagement clinical preference. The distance of the MSE body to the
and posterior positioning of the MSE resulted in better palatal roof is also examined, which should be as close
expansion results [26]. Poorly positioned mini-screws or as possible. Next, the MSE expander, four screws, and
Hsu et al. BMC Oral Health (2023) 23:887 Page 3 of 13

Fig. 1 Scanned surfaces of dental model, mini-screw, and MSE device

dental model are combined and restored as a single file, again. Once the MSE position is confirmed, between
which is then exported to 3Shape Implant Studio soft- the zygomatic buttress bones with bicortical engage-
ware (Fig. 2). ments, the distance from the MSE to the nasal floor is
measured, and the length of the mini-screws is deter-
Step 2. Verification of MSE position mined accordingly.
In 3Shape Implant Studio, the CBCT image is imported
and integrated with the model from step 1. The MSE and
mini-implant position can be verified if their relations to Step 3. Segmentation of U6
the anatomic structures (mid-palatal suture, septal struc- We use the 3Shape Dental System’s software, model
ture, palatal plate, zygomatic buttress bones, inferior builder mode, to isolate the upper first molars from
nasal conchae, and nasal cortical layer) are appropriate the upper dentition. The bridge mode can be applied to
(Fig. 3). ensure parallel paths of insertion for these two molars
Otherwise, we must return to step 1 to modify the (Fig. 4).
MSE position and then proceed to step 2 to verify

Fig. 2 Merged multiple surfaces and positioning

Hsu et al. BMC Oral Health (2023) 23:887 Page 4 of 13

Fig. 3 Importing merged surface with CBCT and verification of appliance position and determination of the appropriate length of the mini-screws.
The actual distance from the inferior surface of MSE to the superior cortical plate of the maxilla can be measured, which were 9.51 mm (anterior)
and 6.97 mm (posterior). Therefore, 11 mm for the anterior and 9 mm for the posterior screws were chosen to achieve bicortical engagement

Fig. 4 Upper first molar segmentation process in software. The insertion path can become parallel when the 16–26 bridge mode was chosen

Step 4. Virtual integration of all information Step 5. MSE transfer index design and model printing
Combining the step 3 model with that of step 1, the Meshmixer offers several ways to design the trans-
MSE, maxillary model, and first molar models are inte- fer index (Fig. 5): (1) the “screw hole” type, the internal
grated into the software. The model is then exported threads were built in the 3DP resin model in advance.
to Meshmixer software for the design of the transfer Therefore, the MSE expander can be placed and con-
index. nected securely and tightly with the 3DP resin model
Hsu et al. BMC Oral Health (2023) 23:887 Page 5 of 13

Fig. 5 The transfer index can be designed to connect the expander with the upper arch model. Three types of MSE transfer indices can be used
through similar designing workflows

by the real mini-screws.; (2) the “screw index” type, The When the final step of this virtual design is complete,
MSE expander can be connected with the 3DP resin a resin model with the expander transfer indices and the
model by the screw indices. Usually, two indices diago- two removable upper first molars is fabricated by 3D
nally are good enough for positioning. But the thin screw printing (Fig. 5).
index is easy to break when the insertion pathway of the
expander screw is not parallel with the insertion pathway Step 6. Selection of U6 band on the 3DP model
of two molar bands; (3) the “cube type”, the position of The appropriate bands are easily selected and precisely
the MSE expander can be marked by some cubes around seated to the 3DP model.
its’ corners. This is the easiest and most durable way
among these three designs. Four cubes can be designed Step 7. Combination of bands with MSE bars
around the corners of the expander to secure its position; The U6 bands and the MSE bars are soldered, and their
and for the vertical position of the expander, four cubes relative positions are maintained. The planned MSE posi-
or a plane of a specific heights can be designed to transfer tion on the software is accurately transferred to the phys-
the vertical position of MSE precisely. ical 3DP resin model (Fig. 6).

Fig. 6 The selected bands were soldered with MSE bars. The whole device has only one path of insertion because of the parallel molar models. The
MSE position was transferred accurately from the virtual design to the physical resin model
Hsu et al. BMC Oral Health (2023) 23:887 Page 6 of 13

Case presentation Treatment progress

A 17-year-5-month-old male patient came for a con- Before the treatment, a cone beam computed tomogra-
sultation with chief complaints of diastema, facial phy and intraoral scans were performed to acquire the
asymmetry, and chin prognathism. Clinically, the data needed for the MSE digital workflow. Following
patient had apparent facial asymmetry with a larger steps 1 through 5, a model with the MSE transfer indices
volume on his right side. His chin deviated to the left was designed and 3D printed. The isolated upper molar
side, and his right side downward occlusal plane cant- crowns in a parallel orientation were sized for bands and
ing was also evident. The lateral profile revealed a they were soldered.
retrognathic maxilla with an excessive lower jaw pro- The patient came to the clinic one week before the MSE
jection (Fig. 7). insertion date for molar separator application (Fig. 9a).
An intraoral examination revealed a bilateral Class On the day arranged for the MSE delivery, the bands
III canine and molar relationship with anterior open- were well-fitted, with the appliance in a proper posi-
bite. The overjet was -5 mm, and the overbite was tion. The four mini-implants were inserted (Fig. 9b,c and
-2 mm. Despite the severe dental compensation, the d). According to the maxillary height measured via the
posterior teeth were still in a bilateral crossbite rela- merged dental and CT file, 1.8 × 11 mm anterior screws
tionship. The upper ­ 2nd premolars were missing and 1.8 × 9 mm posterior screws were chosen for this
(Fig. 7). patient. A CBCT taken immediately after insertion veri-
The panoramic radiograph showed a normal peri- fied an accurate MSE position as a virtually designed and
odontal status with recently extracted lower third bi-cortical engagement of all four mini-implants (Fig. 10).
molar sockets. Regarding a cephalometric analysis, After insertion of MSE, a semi-rapid expansion pro-
the patient had a skeletal Class III relationship with a tocol of one turn per day was instructed [31, 32]. In six
hyperdivergent facial pattern, flared upper incisors, weeks, the required expansion was achieved, and the
and retroclined lower incisors (Fig. 8). bilateral palatal crossbites were corrected (Fig. 11).
One month after the successful maxillary skeletal
expansion, banding and bonding were arranged for lev-
Treatment objective eling and alignment. The maxillary midline diastema
The treatment objective was to correct the facial asym- started to close in the third month after the cessation of
metry and Class III skeletal pattern through a surgical expansion. The MSE was left in place for six months for
treatment: maxillary advancement and mandibular set- retention. After eight months of presurgical orthodon-
back. For the transverse discrepancy, maxillary skeletal tic decompensation, two-jaw surgery was performed:
expansion was planned to avoid a three-piece maxil- maxillary one-piece advancement and mandibular set-
lary surgical procedure. back with rigid fixations. A genioplasty was performed

Fig. 7 Initial extraoral and intraoral photo records

Hsu et al. BMC Oral Health (2023) 23:887 Page 7 of 13

Fig. 8 Initial lateral cephalometric, posteroanterior cephalometric, and panoramic radiographs

Fig. 9 Comparison of the MSE position. a. The separators were placed one week before the MSE insertion date. b. on the virtual plan, a 10 mm
MSE was placed. c. exported resin model, d. the final position in the patient’s mouth. Though the MSE seemed to be slightly shifted in the patient’s
mouth, it was aligned to the bony maxillary suture
Hsu et al. BMC Oral Health (2023) 23:887 Page 8 of 13

Fig. 10 After MSE insertion, CBCT further proved predictability of the digital workflow. The distance of bilateral mini-screws to the mid-palatal
suture were precisely the same for both anteriorly and posteriorly

Fig. 11 Post-expansion intraoral photos. (47 turns of the expander) Buccal tipping of the molars was a frequent side effect of MSE treating adult
patients. The molar bands were then removed to allow dental relapse, leaving only the central MSE-screw combination part to secure sutural bone
consolidation

to reduce chin length and correct asymmetry further Discussion and conclusions
(Fig. 12). Several paradigm-shifting inventions and treatment
The patient showed significant improvement in his modalities in the orthodontic field have changed the
facial esthetics after the surgery. The bilateral facial envelope of tooth movement as well as the decision-
volume became more symmetric, occlusal canting making process, including the application of temporary
was corrected, and his profile became more pleasant. anchorage devices, periodontally accelerated osteogenic
Intraorally, his transverse discrepancy was eliminated, orthodontics or phenotype modification therapy, and
and his periodontal status was well-maintained. The mini-implant assisted rapid maxillary expansion. Before
patient continued to be seen monthly for post-surgical the pioneering report of Lee [15], treating adult patients
detailing (Figs. 13, 14). with transverse skeletal problems required surgical
Hsu et al. BMC Oral Health (2023) 23:887 Page 9 of 13

Fig. 12 Simulation of Orthognathic surgery. Because the transverse discrepancy was corrected with the MSE in the pre-surgical orthodontic
treatment, one-piece maxilla movement was planned

Fig. 13 Post-surgical extraoral and intraoral photos after two-jaw orthognathic surgery after 1 year and 8 months of treatment. Mandibular
prognathism and facial asymmetry were largely improved with a balanced lateral profile. The molars were relapsed to its physiological position,
and the periodontal status remained unchanged

aid, which increased cost and patient morbidity. After activation frequency, all of which affect the final result
MARPE became a generally-accepted approach, cases of expansion [26, 37, 38]. Among them, the bone thick-
with maxillary transverse deficiency or borderline Class ness or density and the gender or age of a patient can-
III cases could be resolved with non-surgical skeletal not be controlled. Consequently, the crucial element
expansion and maxillary protraction in adolescent and is how well we control the remaining factors, and the
young adult patients [15, 17, 33–36]. positioning of the appliance is one of the most impor-
Previous researchers have investigated key factors tant factors in achieving a successful expansion. The
affecting the success rate of MSE, including the appli- term MARPE (mini-implants assisted rapid palatal
ance itself, the anteroposterior position of mini-implants, expander) is loosely used for any expansion device that
the bi-cortical vs. mono-cortical penetration of mini- incorporates mini-implants. Among the countless num-
implants, bone thickness, sex, chronological age, and ber of MARPE designs, they can be divided into two
Hsu et al. BMC Oral Health (2023) 23:887 Page 10 of 13

Fig. 14 Post-surgical radiographs after two-jaw orthognathic surgery

categories from the perspective of implant placements. in anatomical structures, the positioning of the appliance
In the early days of MARPE development, most appli- must be decided with several factors in mind: position of
ances were bone-driven, meaning the mini-implants the zygoma, septal configuration, midpalatal suture ori-
were placed where a large quantity of bone was present. entation, palatal inclination, canting of the palatal vault,
These MARPEs favored the anterior and lateral walls of and thickness of the palatal bone. In the past, MSE was
the palate, which produced more anterior and inferior fabricated by positioning the appliance in the posterior
expansion [22, 23]. The MSE was a unique MARPE that palate with care and consideration of the above factors.
was a resistant-driven system, meaning the mini-implant With the advent of recent digital technology and CBCT
position was designed to overcome the resistance against acquisition, much more precise measures can be taken
the expansion. The resistance against expansion, not only to locate an optimal MSE position. This report offers a
comes from interlocked midpalatal suture, but also from fully digitized solution for MSE positioning to increase
the zygomatic buttress bones, interlocked pterygopala- the success rate and avoid unwanted expansion results
tine sutures, and other peri-maxillary sutures [39, 40]. (Figs. 15, 16).
Most of the resisting structures mentioned above are in Commercially available MARPE appliances often com-
the posterior aspect of the maxilla, and a posterior force bine two features in one: an expander and a surgical stent.
vector is required to overcome the resistance. The MSE The expander provides the line of force action, while the
appliance should be positioned in the posterior palate surgical stent aids in inserting the mini-implants in the
between the right and left zygomatic buttress bones [28, desired location. To identify the best position for both
30]. However, the posterior palate has a relatively thin parts, several digital workflows have been proposed by
bone, and the mini-implants must be placed in a secure previous researchers using various expander designs
area, immediately lateral to the midpalatal suture where [28–30, 41]. Often these systems require a two-step pro-
the bone has a higher density and greater thickness cess: mini-implant insertion by a digitally produced stent
[25]. The min-implants must be engaged bicortically to and retrofitting of MARPE onto the mini-implants by
ensure the stability [26]. Because of individual variation digital processing. The surgical stent is not required for
Hsu et al. BMC Oral Health (2023) 23:887 Page 11 of 13

Fig. 15 This is another case with an unfavorable expansion result using the traditional MSE fabrication process: unusual expansion pattern (white
arrow) revealed by CBCT superimposition (white line, initial; green line, post-expansion). The canted palatal plane caused the right TADs inclination
toward the maxillary suture during inserting MSE. The appliance in this case was thus removed to allow relapse of the dentoalveolar tissue

Fig. 16 In another case with canted palatal plane, using digital workflow can secure the MSE in a correct position for intended force vector, avoid
being mislead by the shape of palate

MSE since the appliance comes with guiding slots for the based on CBCT information, and then digitally designed a
mini-implants, and the appliance itself serves as a surgical position guide to replicate the same MSE position on the
guide, eliminating the retrofitting of the appliance to the stone model. Lo Giudice et al. developed a similar method
mini-implants. An optimal MSE position, based on the to locate a negative template of the MSE device on the digi-
desired force vector, determines the mini-implant position tal model and printed it as a reference for band soldering.
without the two-step procedure. Consequently, finding an Both approaches embraced the idea of digital design, but
optimal MSE position is extremely important. Cantarella the final process of band soldering was not incorporated,
et al. combined a segmented maxillary bony structure from resulting in an extra appointment for the pick-up impres-
CBCT and a dental model surface from an intraoral scan- sion. In this study, upper first molar tooth dies were fabri-
ner, placed a digital MSE template in an optimal position cated and printed digitally with a parallel path of insertion
Hsu et al. BMC Oral Health (2023) 23:887 Page 12 of 13

so that the technician could choose an accurate band size 2. Howe RP. Palatal expansion using a bonded appliance. Am J Orthod.
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Acknowledgements
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Authors’ contributions
expansion before orthognathic surgery for a patient with severe mandib‑
KWCC designed and implemented the digital workflow, treated the case,
ular prognathism. Am J Orthod Dentofacial Orthop. 2010;137(6):830–9.
wrote and reviewed the manuscript. LFH contributed to the writing of the
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manuscript. WM and SCC contributed to the reviewing and revising the
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manuscript. All authors discussed and contributed to the final manuscript.
17. Lübberink G, Nienkemper MWB, Ludwig B, Drescher D. Nonsurgi‑
cal treatment of a mature adult class III patient. J Clin Orthod.
Funding
2014;48(11):697–702.
This research received no external funding.
18. Paredes N, Colak O, Sfogliano L, Elkenawy I, Fijany L, Fraser A, et al.
Differential assessment of skeletal, alveolar, and dental components
Availability of data and materials
induced by microimplant-supported midfacial skeletal expander (MSE),
The datasets used and/or analysed during the current study available from the
utilizing novel angular measurements from the fulcrum. Prog Orthod.
corresponding author on reasonable request.
2020;21(1):18.
19. Choi SH, Shi KK, Cha JY, Park YC, Lee KJ. Nonsurgical miniscrew-assisted
Declarations rapid maxillary expansion results in acceptable stability in young adults.
Angle Orthod. 2016;86(5):713–20.
Ethics approval and consent to participate 20. Lim HM, Park YC, Lee KJ, Kim KH, Choi YJ. Stability of dental, alveolar, and
Not applicable. skeletal changes after miniscrew-assisted rapid palatal expansion. Korean
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Consent for publication 21. Jesus AS, Oliveira CB, Murata WH, Suzuki SS, Santos-Pinto AD. Would
Written informed consent for publication of the patient’s details and photos midpalatal suture characteristics help to predict the success rate of
was obtained from the patient. miniscrew-assisted rapid palatal expansion? Am J Orthod Dentofacial
Orthop. 2021;160(3):363–73.
Competing interests 22. Ludwig B, Baumgaertel S, Zorkun B, et al. Application of a new
The authors declare no competing interests. viscoelastic finite element method model and analysis of miniscrew-
supported hybrid hyrax treatment. Am J Orthod Dentofacial Orthop.
2013;143(3):426–35.
Received: 12 March 2023 Accepted: 27 October 2023 23. Lagravere 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 Dentofacial Orthop. 2010;137(3):304 e1-12. discussion 04-5.
24. Elkenawy I, Fijany L, Colak O, et al. An assessment of the magnitude,
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