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Contents lists available at ScienceDirect

Journal of the World Federation of Orthodontists

journal homepage: www.jwfo.org

Review Article

Biomechanics of conventional and miniscrew-assisted rapid palatal

expansion
Shivam Mehta a, Sarah Abu Arqub b, Meenakshi Vishwanath c, Madhur Upadhyay d,
Sumit Yadav e,∗
a
Department of Orthodontics, Texas A&M University School of Dentistry, Dallas, Texas
b
Division of Orthodontics, University of Florida Health, Gainesville, Florida
c
Program Director, Orthodontic Section, Department of Growth and Development, UNMC College of Dentistry, Lincoln, Nebraska
d
Division of Orthodontics, Program Director, Orthodontic Fellowship Program, University of Connecticut Health, Farmington, Connecticut
e
Henry and Anne Cech Professor of Orthodontics, UNMC College of Dentistry and Children’s Hospital and Medical Center, Lincoln, Nebraska

a r t i c l e i n f o a b s t r a c t

Article history: Posterior Crossbite is a common condition resulting because of transverse maxillary deficiency. The
Received 19 November 2023 growth of the craniofacial complex finishes first in the transverse dimension, followed by sagittal and
Revised 1 March 2024
vertical dimensions. Conventional rapid palatal expansion (RPE) appliances are commonly used to cor-
Accepted 4 March 2024
rect transverse maxillary deficiency. Although RPE is efficient in correcting posterior crossbite, it results
Available online xxx
in dental side effects such as buccal tipping of maxillary molars, root resorption, bone dehiscence, and
Keywords: relapse. Mini-implant-assisted RPE has been introduced to increase the skeletal effects of expansion espe-
Palatal expansion technique cially in patients with increased maturation and greater interdigitation of midpalatal suture. This article
RPE will review the biomechanics of RPE and mini-implant-assisted RPE. Additionally, the different designs of
MARPE MARPE and the long-term clinical effects of expansion appliances will also be discussed in detail.
Biomechanics © 2024 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.
Bone-anchored expansion

1. Introduction first molars and first premolars [1,3,4]. When the RPE appliance
is activated by opening the expansion screw, the maxillary mo-
Transverse maxillary deficiency is a common condition in pa- lars experience a transverse force leading to expansion of maxillary
tients presenting for orthodontic treatment with a prevalence of 4% arch. However, there are some disadvantages such as buccal tipping
to 17% in Europe and the United States [1]. Growth of craniofacial of maxillary molars, root resorption, bone dehiscence, and relapse
complex in the transverse dimension precedes sagittal and verti- [3–5].
cal aspects. Therefore, timing of the correction of transverse max- With the objective of increasing the skeletal effects of expan-
illary deficiency is vital. Maxillary expansion has been a vital com- sion and minimizing dental side effects, mini-implant-assisted RPE
ponent for correction of transverse maxillary deficiency for over (MARPE) was introduced. MARPE differs from RPE as they are an-
100 years [2]. Maxillary expansion can be undertaken with con- chored to mini-implants inserted in the palatal vault. In this review
ventional rapid palatal expansion (RPE) which is a tooth-borne ap- article, the biomechanics pertaining to RPE and MARPE appliances
pliance as it is anchored to maxillary first molars or both maxillary will be discussed. To understand the biomechanics of MARPE, it
is necessary to understand the biomechanics of RPE, which would
let us delineate the similarities and differences between RPE and
Funding: The authors have not declared a specific grant for this research from MARPE and between different designs of MARPE appliances.
any funding agency in the public, commercial, or not-for-profit sectors. In understanding the first principles for maxillary expansion, it
Competing interests: Authors have completed and submitted the ICMJE Form for is important to note that three main things play an important role
disclosure of potential conflicts of interest. None declared. in the type of movements that follow RPE.
Provenance and peer review: Commissioned and internally peer reviewed
∗
Corresponding author: Department of Growth and Development, Room 2432,
UNMC College of Dentistry, 40 0 0 East Campus Loop South, Lincoln, Nebraska 68583- (i) Center of resistance and anatomy of maxilla.
0740. (ii) Appliance system.
E-mail address: [email protected] (S. Yadav). (iii) Forces, Stress, and Strain.

2212-4438/$ – see front matter © 2024 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ejwf.2024.03.002

Please cite this article as: S. Mehta et al, Biomechanics of conventional and miniscrew-assisted rapid palatal expansion, Journal of the
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week to 3.5 activations per week resulting in about 2 lbs of pres-

sure [3,5,21]. Whereas, in RPE, the activation frequency ranges from
two to four per day with one activation amounting to 0.25 mm
of screw opening [3]. In RPE, the required expansion is usually
achieved in 2 to 3 weeks, generating about 10 to 20 lbs of pres-
sure, which may result in a midline diastema between the maxil-
lary central incisors, indicative of opening of midpalatal suture [3].

3. Appliance anchorage system

3.1. Conventional rapid palatal expansion

Conventional RPE appliances are anchored to the maxillary

teeth or the palatal tissues and can be divided into two main
groups: 1) Tooth-borne appliances, and 2) Tooth and tissue-borne
appliances. Tooth-borne expansion appliances are anchored to the
maxillary molar and/or premolar teeth whereas tooth and tissue-
borne expansion appliances derive anchorage from both teeth and
palatal tissue through acrylic pads [22–24]. For bonded expansion
appliances, an acrylic base is extended on the occlusal, facial, and
Fig. 1. Schematic figure of skull showing the center of resistance of nasomaxillary
lingual aspects of maxillary posterior teeth to prevent maxillary
complex. (A) nasion, (B) anterior nasal spine, (C) maxillary first molar, (D) inferior
aspect of pterygomaxillary suture, (E) center of resistance of maxilla posterosupe- molar extrusion after maxillary expansion in hyperdivergent skele-
rior ridge of pterygomaxillary fissure, (F) zygomaticotemporal suture, (G) zygomati- tal pattern [3].
cofrontal suture, (H) frontomaxillary suture.
3.2. MARPE appliances

1.1. Center of resistance and anatomy of maxilla

MARPE appliances derive anchorage from mini-implants in-
serted in the palatal vault. If MARPE appliances are anchored only
The center of mass of a body is the point at which all the mass
to the mini-implants, they are referred to as bone-anchored ap-
of a body appears to be concentrated [6]. However, teeth and oral
pliances, whereas if MARPE appliances are anchored to both mini-
structures such as maxilla are restrained systems because of the
implants and maxillary teeth, they are referred to as hybrid MARPE
surrounding structures, abutting against them and therefore, the
appliances (Fig. 3) [25]. MARPE can be further classified based
term center of resistance has been assigned through which if the
on when the mini-implants are inserted such as the mini-implant
force is applied, would result in a straight-line motion [6]. Maxil-
first approach and appliance-first approach. Additionally, it can be
lary bone consists of two halves joining at the midline through the
classified based on the design of expander such as two-arms or
midpalatal suture [7–9]. Each maxilla is connected with nine other
four-arms, length of mini-implants, and number of mini-implants
bones of the craniofacial skeleton through cranial and circummax-
(Fig. 3). The biomechanical effects of MARPE appliance depend on
illary sutures [10–13].
various factors such as the appliance design, magnitude of force,
The Cres of maxilla and the nasomaxillary complex have been
point of force application, direction of force, and material used for
experimentally located at the posterosuperior ridge of the ptery-
expansion appliance [26].
gomaxillary fissure on the mid-sagittal plane (Fig. 1) [14]. Other
than the pterygomaxillary fissure, the zygomatic bone—mainly zy-
3.3. Forces after expansion
gomaticotemporal and zygomaticofrontal sutures—has also been re-
ported to be the main resistance area for maxillary expansion [15–
When expansion appliances are activated, forces upward of 16.6
18]. The stretching of the cheeks was hypothesized at one time
to 34.8 lbs (7.54–15.8 kg) are produced [27]. Issacson et al. reported
to cause resistance to expansion, but it was observed to be 0.6
that when expansion appliances are cemented, the appliance itself
g/cm2 per mm of expansion and therefore considered to be neg-
produces expansion or constriction forces as a result of cementa-
ligible [19]. Another important parameter to consider for maxillary
tion which ranged from 0 to 3 lbs (0–1.36 kg). With first activation
expansion is the Cres of maxillary molar, which lies close to the
of RPE, forces ranging from 3.7 lbs (1.68 kg) to 7 lbs (3.18 kg) are
root furcation area [20]. When the expansion forces are applied on
exerted. There is a decay in force levels within 3 to 5 minutes by
the lingual aspect of the crown of maxillary molar, it results in tip-
0.2 lbs (0.09 kg) to 2 lbs (0.91 kg) [28]. With the second activation,
ping of maxillary molar in buccal direction because of the point
forces ranging from 2.5 lbs (1.13 kg) to 8 lbs (3.63 kg) are exerted,
and direction of force application away from the Cres of the molar.
which again rapidly decay by 0.3 lbs (0.14 kg) to 4.1 lbs (1.86 kg)
within minutes [28]. A similar pattern is seen with subsequent ac-
2. Appliance system tivations (Fig. 4) [24,28]. When the expansion screws are activated
by 20 turns, expansion forces of over 157.8 N (16.09 kg) to 215 N
The clinical operation of the expansion appliances for maxillary (21.92 kg) are produced with different tooth-borne expanders as
expansion is based on several parameters as shown in Fig. 2. shown in Fig. 4 [24,28].
The following are the important points to consider with forces
2.1. Expansion protocol after maxillary expansion: 1) The cycle of force activation and de-
cay happens after every turn/activation of the expansion appliance
Maxillary expansion can broadly be classified into (i) Slow (Fig. 4A) [24,28]. (2) The nature of forces with expansion is cumu-
palatal expansion, and (ii) RPE based on activation rate of the ex- lative [28]. 3) There is a constant presence of force between activa-
pansion screw. Slow expansion ranges from two activations per tions [28]. 4) The force-activation curve shows an increase with an

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Fig. 2. Classification of expansion appliances.

Fig. 3. Different types of MARPE appliances. (A) mini-implant first approach (hybrid MARPE with two mini-implants); (B) mini-implant first approach (bone-anchored MARPE
with two mini-implants); (C) appliance first approach (hybrid MARPE with four mini-implants).

Fig. 4. Forces produced and rapid decay after activation of expansion appliances. This graph was constructed to approximate the consensus from the available literature on
the forces after expansion appliances [24,28].

almost linear trend in the first ten activations and then decreases screw with lower rigidity generates less force per activation and
and a plateau is reached at 18–20 activations (Fig. 4B) [24,28]. 5) total force generated after 20 activations is less than the other two
Expansion appliances with the arms parallel to the screw guides expanders.
exhibit higher rigidity and greater force per activation compared
to expanders with arms perpendicular to the screw guides [24]. 6) 3.3.1. Two-arm and four-arm appliances
Expansion appliances with the two-arm design are more rigid and The common issues in clinical use of expansion appliances are
generate more force per activation than the four-arm design [29]. patient discomfort with palatal appliances and maintenance of oral
Another part of expansion appliances that influences the force hygiene. Therefore, there has been an efflux of appliances targeted
system is the retention arms of expansion screw. Different expan- to decrease bulkiness and streamline the design for increased pa-
sion screws with the same cross-sectional diameter show differ- tient comfort such as two-arm expansion appliances compared to
ing loading capacities based on the force, stress, and deformation the four-arm appliances [29–31]. Maximum forces produced by
parameters of retention arms. Importantly, the higher the stiffness two-arm expansion appliances range from 288N (29.37 kg) to 303
of expansion screw (body and arms), the higher the force gener- N (30.9 kg), whereas the four-arm appliances generate forces rang-
ated by the expander. It could be seen in Fig. 4B [24,28] that the ing from 124 N (12.64 kg) to 227 N (23.15 kg) [29].

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Fig. 5. Graph showing the levels of stress on sutures after RPE. This graph was constructed to approximate the consensus from the available literature on the stresses after
RPE and MARPE [26,32–34].

Because of the higher force per activation with two-arm ap- plane has been reported to be the superior aspect of frontozygo-
pliances than four-arm appliances, the deformation of the expan- matic suture [39]. Because of the rotational fulcrum, it has been
sion key, retention arms, or screw bodies is also higher in two-arm reported that frontomaxillary suture undergoes tensile stress dur-
appliances [29]. This gradual deformation in the structure of the ing maxillary expansion with MARPE. However, these findings need
screw does not allow more than 15 activations in two-arm appli- to be corroborated with more studies on identifying the center of
ances whereas the four-arm appliances can be activated to 20 or rotation of maxilla with MARPE appliances.
even 24 turns [24,29]. The increase in deformation of the screw The center of rotation of maxilla in horizontal plane after RPE
with activation is because of an increase in force and a decrease in has been observed to be between the medial and lateral ptery-
the stiffness of the expansion screw because the length of the arms goid plates (Fig. 6B) [22,35–37]. The pyramidal-shaped separation
increases with opening of the screw. However, as both designs lead is observed with the base of pyramid in the anteroposterior plane
to application of a high magnitude of forces, both two-arm and located toward the anterior side [17,18,32,35–37,40]. This is at-
four-arm appliances have been shown to cause opening of the mid- tributed to strong interdigitation between the sphenoid bone and
palatal suture [30]. For clinical demands of RPE, it has been sug- maxilla through pterygomaxillary connections [17,18,36,40]. In the
gested that forces should range from 73N (7.44 kg) to 154N (15.70 horizontal plane, the center of rotation with MARPE appliances has
kg) [27,30]. Whether two-arm or four-arm designs are used with been reported to be located near the proximal portion of the zygo-
conventional RPE appliances or MARPE appliances, the fundamen- matic process of the temporal bone [41]. However, further studies
tals of biomechanics stay the same. are needed on this topic with MARPE appliances to have conclusive
evidence regarding the center of rotation of maxilla with different
3.4. Stress Levels and center of rotation types of MARPE appliances.
With conventional expansion, forces are applied directly to
The force system created by the expansion screws is transferred maxillary molars, and stresses radiate to three main buttresses of
as stress (force/surface area) on the maxillary teeth, alveolar bone, midfacial cranial complex—the nasomaxillary-buttress, zygomati-
sutures, and adjacent structures. It has been observed that after comaxillary buttress, and pterygomaxillary-buttress [33,34]. With
maxillary expansion of approximately 5 mm with RPE, significant MARPE, stresses are mainly noted around the mini-implants, and
stresses are generated on the cranial and circummaxillary sutures. a decreased amount of stresses are observed on zygomaticomaxil-
The lowest stresses are observed on zygomaticomaxillary suture, lary sutures, zygomaticomaxillary buttress, and medial orbit. Over-
whereas the highest stresses are on nasomaxillary suture (Fig. 5) all, when compared to RPE, MARPE shows less stress build-up
[26,32–34]. Furthermore, depending on the orientation of suture, (Fig. 6 [22,35–37]). These findings have been corroborated by an-
it can experience tensile or compressive stress. With maxillary ex- other study in which the maximum stresses after MARPE appli-
pansion, there is a compressive stress on superior portion of fron- ances have been observed at the midpalatal suture, followed by
tomaxillary suture and tensile stress on inferior portion because of lower amounts of stresses around the pterygomaxillary suture and
rotation of maxilla in the frontal plane as palates expand. zygomaticomaxillary suture [26]. In addition, on comparing the ef-
The center of rotation of maxilla in the frontal plane after RPE fects of MARPE and RPE on cranial and circummaxillary sutures,
is at frontomaxillary suture [22,35,36], whereas Gautam et al. have the only difference observed in long-term was the increased width
observed it to be at superior orbital fissure (Fig. 6A) [22,35–37]. of midpalatal suture in MARPE as compared to RPE [42]. Further-
Regardless, it can be inferred that center of rotation of maxilla more, the highest stresses with MARPE are concentrated on the
is much higher than incisor tip. This is the reason for pyramidal- maxillary bone followed by pterygoid bone and zygomatic bone
shaped separation after maxillary expansion with base of pyramid, with minimal stresses on the nasal and frontal bone [26].
in the vertical plane, located toward oral side. This also explains From a biomechanical perspective, the placement of the expan-
the lateral displacement of the nasal cavity walls and increase in sion screw should be as close to the center of resistance as possi-
the nasal width with lowering of the palatal plane. The nasal bone, ble, to maximize the translatory effect and minimize the rotational
specifically the posterosuperior part of nasal cavity tends to move effects. With MARPE, the point of force application can be modi-
medially because the center of rotation approximates superior or- fied as the force is applied deep in the palatal vault and potentially
bital fissure or frontomaxillary suture which leads to compression closer to the center of resistance of maxilla [43]. Consequently, af-
in nasal region after maxillary expansion [22,23,32,35,37,38]. With ter expansion with only bone-anchored MARPE appliances, most
MARPE appliances, the center of rotation of maxilla in the frontal of the stress is distributed around the midpalatal suture, maxil-

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Fig. 6. (A) Figure showing the center of rotation of maxilla with RPE in the frontal plane near the frontomaxillary suture or superior orbital fissure [22,35–37]. The structures
of the nasomaxillary complex below the center of rotation such as the inferior aspects of nasal cavity and maxillary molars are displaced laterally after expansion. The
structure above the center of rotation such as the posterosuperior part of nasal cavity tends to move medially leading to compression of the nasal region after expansion; (B)
figure showing the center of rotation of maxilla with RPE in the horizontal plane near the medial and lateral pterygoid plates. The structures closer to the center of rotation
such as the posterior aspect of the midpalatal suture are displaced less than the anterior aspect of the midpalatal suture leading to a triangular sutural opening.

Fig. 7. Graph showing the levels of stress on mini-implants after different designs of MARPE—Hybrid MARPE and bone-anchored MARPE. This graph was constructed from
the available literature on the stresses after hybrid and bone-anchored MARPE [44].

lary bone, pterygoid bone, posterolateral aspects of hard palate, lighter forces to the midpalatal suture than bone-anchored MARPE
near the mini-implants and anterior portion of the dentoalveolar [44].
region [26,33]. With conventional RPE, molars have been shown
to undergo compressive stress of about 57.19kg/mm2 at the level 3.5. Length of mini-implants
of the molar crown, whereas crowns of canine, first premolar, and
second premolar experience lesser amounts of stress in the range MARPE can be designed with mini-implants exhibiting mono-
of 16 to 25 kg/mm2 . With MARPE appliances, the force levels and cortical or bi-cortical anchorage. With mono-cortical anchor-
stress distribution vary depending on the type of MARPE appliance age, mini-implants derive anchorage only from the palatal bone
namely, the bone-anchored MARPE or a hybrid MARPE. whereas in bi-cortical anchorage, longer mini-implants are used
The main difference in the biomechanics of the hybrid and to achieve cortical anchorage from the palatal bone and the nasal
bone-anchored MARPE is the concentration of a high magnitude of floor. When comparing mono-cortical anchorage to bi-cortical an-
stress (almost double) around the mini-implants in bone-anchored chorage, conflicting findings have been reported as to whether one
MARPE as compared to hybrid appliances (Fig. 7 [44]). With a technique is superior to the other. Some finite element method
hybrid appliance, the delivered force is divided onto two struc- (FEM) studies have shown that bi-cortical anchorage for MARPE re-
tures namely the midpalatal suture via mini-implants and to max- sults in greater stress distribution and displacement with reduced
illary molars. Accordingly, hybrid MARPE exerts a lower amount deformation of mini-implants [26,45,46]. However, FEM studies
of stress on midpalatal and circummaxillary sutures than bone- by other authors have found no difference in stress distribution
anchored MARPE [44]. Thus, bone-anchored MARPE may be indi- with either mono-cortical or bi-cortical anchorage [47]. Addition-
cated for patients with buccal plate fenestration, or periodontal is- ally, clinical studies have demonstrated that bi-cortical anchorage
sues whereas a hybrid design may be more useful in patients with of MARPE does not result in increased skeletal expansion or im-
decreased bone density, reduced cortical to cancellous bone ratio, prove the opening of midpalatal sutures [48,49]. In fact, Oliveira
and decreased quality of micro-architecture of bone as it delivers et al reported that mono-cortical anchorage was more successful

Please cite this article as: S. Mehta et al, Biomechanics of conventional and miniscrew-assisted rapid palatal expansion, Journal of the
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in opening of midpalatal suture compared to bi-cortical anchorage height of maxillary first molars, however, the reduction in vertical
[48]. Furthermore, a recent randomized clinical trial showed that buccal alveolar bone height is greater in RPE compared to MARPE
mini-implant length had no effect on the success rate of opening of [4]. Thus, it is important to note that MARPE can be advantageous
midpalatal sutures [49]. However, it is important to note that mini- in reducing dental side effects because of expansion, but the side
implants of less than 8 mm in length have been shown to have an effects cannot be completely eliminated.
increased failure rate according to a recent meta-analysis [50,51]. In
summary, success rates with mono-cortical or bi-cortical anchorage 4. Long-term stability after rapid palatal expansion
do not differ significantly provided mini-implants less than 8mm in
length are not used for the MARPE appliances. With RPE, overexpansion is a norm and not an exception. Once
the expansion is achieved, the same appliance is continued for a
3.6. Two mini-implants vs four mini-implants specified time for retention. Is expansion stable? – even after an
extended retention period. If we define stability, as no deviation
Biomechanically the difference between MARPE with two mini- from the expanded position, then the answer is “No.” [2] However,
implants and four mini-implants lies in the stress distribution if we adopt a more generous take on expansion and define stability
to mini-implants. In MARPE appliances with four mini-implants, as an increase beyond normal growth and development, the argu-
lower maximum stresses are observed on the mini-implants af- ments still most likely weigh heavier on the side that expansion is
ter expansion than MARPE with two mini-implants [47,52]. This is not stable [2].
because the forces and the resultant stresses are distributed over When comparisons were made with RPE and MARPE appliances
more mini-implants and therefore, the net stress on each mini- using cone beam computed tomography in a sample from a ran-
implant is lower, which reduces the chances of deformation of the domized controlled clinical trial, it was observed that the imme-
mini-implants. MARPE with three mini-implants is usually not rec- diately after expansion, RPE and MARPE led to an increase in nu-
ommended as a higher deformation of isolated mini-implant is ob- merous dental and skeletal parameters compared to treated con-
served compared to symmetrical designs such as two or four mini- trols [4,42,53,56,57]. However, post-treatment (average: 2 years 8
implants [52]. MARPE with two mini-implants is indicated for ado- months after the initial), it was observed that there were no differ-
lescents in whom the midpalatal suture is not highly interdigitated ences in the amount of root resorption, condyle-fossa relationships,
whereas MARPE with four mini-implants could be used for maxil- skeletal maxillary width, intermolar width, maxillary molar tipping,
lary expansion in adults because of higher anchorage requirement maxillary molar extrusion, alar base width, cranial and circummax-
and difficulty in opening the suture [52]. illary sutures (except midpalatal suture) between MARPE, RPE, and
controls [4,42,53,56,57]. The differences observed in these studies
3.7. Clinical effects of RPE, bone-anchored MARPE, and hybrid MARPE between the three groups at post-treatment were: MARPE resulted
in an increase in the width of midpalatal suture at incisor, canine,
The effects of conventional RPE and MARPE appliances can be and molar levels than RPE [42]. RPE led to an increased vertical
understood as occurring in three parts: 1) Buccal tipping of max- buccal bone loss compared to controls at post-treatment [4]. Both
illary molars and/or premolars, 2) Alveolar bone bending of maxil- MARPE and RPE led to a minimal decrease in nasal septal deviation
lary molars and/or premolars, 3) Opening of midpalatal suture re- angle in comparison with controls [58]. MARPE led to an increased
sulting in separation and rotation of maxillary halves. posterior nasal cavity width compared to RPE and controls [58].
With RPE, the forces are applied directly to maxillary molars It has been reported that expansion of 6 mm with RPE, after 5
and the stresses radiate to the three main buttresses. This results in years, results in about 40% decrease and a net expansion of 3 to 4
buccal tipping of maxillary molars along with alveolar bone bend- mm [1]. On the other hand, when normal growth is observed be-
ing and opening of the midpalatal suture in young patients leading tween the ages of 10 years to 18 years, there is an increase of about
to separation of maxillary halves. When the MARPE appliances are 3 mm in maxillary arch width [8]. Therefore, a net gain of 1mm of
activated, there is a difference in the stress distribution compared expansion is achieved with appliances when compared with nor-
to RPE. In bone-anchored MARPE appliances, the force is exerted mal growth. This could result from either skeletal maxillary expan-
primarily on the midpalatal suture leading to separation and rota- sion, dental tipping, dentoalveolar tipping, measurement error, or
tion of maxillary halves. However, it also results in alveolar bone a combination of them. These observations are with RPE, but what
bending of the molars [44]. The reason for vestibular inclination of happens with MARPE in the long-term? The literature on long-term
maxillary molars after bone-anchored MARPE is primarily alveolar observations after MARPE is scarce as compared to that of RPE. Fur-
bone bending rather than pure dental tipping. On the other hand, ther long-term observations after MARPE should be performed to
the hybrid MARPE results in higher stress on maxillary molar than understand the long-term stability after expansion.
bone-anchored MARPE resulting in buccal tipping of maxillary mo-
lar crown with the root apex being displaced in the opposite direc- 5. Strains exerted after expansion
tion [44].
Buccal tipping of maxillary molar is significantly correlated with The strain at a physiologic level is usually expressed as micro-
loss of alveolar bone and root resorption of the mesiobuccal root strain (με ) which is equal to 10−6 strain [59]. To understand bone
of maxillary first molars [4,53]. The dental side effects can be re- adaptation, it is necessary to understand the term minimum effec-
duced but not eliminated with the use of bone-anchored MARPE tive strain (MES) proposed by Frost [60]. MES describes the mini-
because of the vestibular inclination of the molars caused by alve- mum threshold of strain necessary to evoke adaptive architectural
olar bone bending [54]. An assessment of MARPE appliances has bone modeling [60–62]. Strains below MES do not evoke the neces-
demonstrated a reduction in the buccal cortical surface after max- sary bone modeling. MES is necessary to understand how mechani-
illary expansion because of high stresses along the buccal alveo- cal loads cause architectural adaptations as it encompasses the key
lar bone after expansion [55]. However, recent studies have shown properties of living lamellar bone and its intermediary organiza-
that there are some advantages of using MARPE over RPE [4,53]. tion with a range from 8 × 10 −4 to 2 × 10−3 unit bone surface
Immediately after expansion, both MARPE and RPE are reported to strain [60–62]. Therefore, to generate effective bone remodeling af-
result in a significant reduction in the vertical buccal alveolar bone ter maxillary expansion with RPE or MARPE, it is necessary to gen-

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Fig. 8. Graph showing the levels of maximum strains generated after MARPE and the MES as proposed by Frost. The maximum strain generated by MARPE is much lower
than that MES proposed by Frost. This graph was constructed from the available literature on the strain as proposed by Frost and strain after bone-anchored MARPE [60–63].

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Please cite this article as: S. Mehta et al, Biomechanics of conventional and miniscrew-assisted rapid palatal expansion, Journal of the
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