[Document title]

Faculty of Dental Medicine (Cairo-Boys)

Department of Orthodontics

Skeletally-Anchored Maxillary Expansion:

Promising Effects and Limitations

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
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CONTENTS

- Introduction.
- Maxillary transverse deficiency.
- Anatomy of circummmaxillary sutures.
- Introduction of rapid maxillary expansion.
- Indications of rapid palatal expansion.
- Effects of tooth-borne rapid maxillary expansion.
- Introduction of skeletally anchored maxillary
expansion.
- Rapid maxillary expansion in adult patient.
- Retention and stability after skeletally anchored
maxillary expansion.
- Limitations of skeletally anchored maxillary
expansion.
- Referances.

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INTRODUCTION (1-11)
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.
Maram A.M., studied the prevalance 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.(1)

The most common findings in the maxillary transverse deficiency are

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, 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.
A common malocclusion in patients seeking orthodontic treatment can be
either a unilateral or a bilateral malocclusion of the deciduous, mixed, or
permanent dentition. The most common form is a unilateral presentation with

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a functional shift of the mandible toward the crossbite side, which occurs in
80% to 97% of cases.
DIAGNOSTIC AIDS (Trnsverse analysis)
Ashley Howe Analysis(12)
Determination of total tooth material (TTM)
Determination of premolar diameter (PMD): from the tip of the buccal cusp of one
first premolar to the tip of the buccal cusp of opposite first premolar (PMD).
Determination of premolar basal arch width (PBAW): The measurement of width
from canine fossa of one side to another.
The PMBAW and the PMD are compared, if the PMB-AW is greater than the
PMD. then it is an indication that arch expansion is possible. If on the other
hand, the PMBAW is less than PMD. then arch expansion is not possible.
To achieve a normal occlusion with a full complement of teeth, the basal arch
width at the premolar region (PMBAW) should be 44% of the sum of mesiodistal
widths of all the teeth mesial to the second molar (TIM).
Pont's Index: (13) Proposed a method of determining the ideal dental arch width in
the premolar and the first molar areas based on the sum of the width of upper
maxillary incisors.
Compared between the measured and calculated (from his formula) premolar
and molar values.
Linder Harth analysis: (14) Edited Pont’s formula.
KorKhaus analysis: (15) the same; But also utilizes a perpendicular measurement
made from a point in between the two maxillary incisors to the midpoint of the inter
premolar line. According to Korkhuus for a given width of the upper incisors, a
specific value of the distance between the midpoint of the inter premolar line to the
point between the two maxillary incisors should exist. An increase in this
perpendicular measurement denotes proclination of the upper anterior teeth, while a
decrease in this value denotes retroclined upper anteriors.

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Andrews analysis of six elements(16)

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.

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).
Rapid Palatal Expansion (RPE) uses a tooth-borne appliance with a center
jackscrew, it is reliable technique to correct this problem for adolescent patients.
Recently, Micro-implant Assisted Rapid Palatal Expanders (MARPE) have been
introduced as a simple modification of Rapid Palatal Expansion (RPE).

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CIRCUMMAXILLARY SUTURES(5-8, 17-19)

A Sutures running sagitally and articulating directly to maxilla: the
intermaxillary, midpalatal and nasomaxillary sutures.
B Sutures running coronally and articulating directly to maxilla: the
frontomaxillary, pterygo-maxillary, Lacrimo-maxillary, Ethmoido-maxillary
and the zygomatico-maxillary suture.
C Sutures running sagittally but articulating indirectly to the maxilla: the
internasal and zygomaticotemporal sutures.
D Sutures running coronally but articulating indirectly to the maxilla: the
frontonasal, fronto zygomatic 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.

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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 and the posterior
segment after the transversal suture.
Ossification of the suture has been considered as a limiting factor for rapid
palatal expansion.

Surrounding and buttressing structures:

- The sphenoid bone that forms the midsagittal part of the anterior and middle
portions of the cranial base lies just posterior to the maxilla.
- The pterygoid plates of the sphenoid, although bilaterally positioned, do not
have a midsagittal suture that allows them to be displaced laterally.
- The pyramidal processes of the palatine bones interlock with the pterygoid
plates.
- 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.
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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. Meanwhile some studies showed that some patients had no sign of
fusion of the mid-palatal sutures at the age of 32 and 54.
Haas(17) 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(18) 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. 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. The
maxilla articulates with ten other bones of the face and cranium.
Persson and Thilander(19) 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;

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- 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. They suppose that, the closure of palatal sutures begins in general terms, at
about the same age but does not advance to the same degree as does the closure of
the cranial vault sutures. Wide variations among individual should be expected.

INTRODUCTION OF RAPID MAXILLARY EXPANSION

Rapid maxillary expansion (RME) is a dramatic procedure with a long history.
Angell(20) reported on the procedure in 1860, and since then it has gone
through periods of popularity and decline. In the late 1940’s Graber(21) advocated
RME for the treatment of cleft lip and palate patients. Since then clinicians have
increasingly included RME in the treatment of their patients. Although clinicians
agree about many of the indications for and outcomes of RME, numerous
disagreements persist about the procedure.
Haas(12), Isaacson and Murphy(22) advocated splitting of the midpalatal
suture to widen narrow maxillary arches. Graber believed that, the technique was
originally dropped because of the development of open bites, relapse and the fact
that, the improvement of nasal breathing was only temporary. Furthermore,
orthodontic appliances routinely achieve the needed maxillary intercanine and
intermolar expansions.
Although, a lot of disagreements did exist, since Haas introduced his
appliance in the 1950’s and conducted a study involving pigs and confirmed the
efficacy of expanding both the maxilla and nasal cavity, rapid maxillary expansion
gained a wide popularization and acceptance among clinicians. He followed this
animal study with a clinical trial on human patients in 1961. The results of his study
proved the benefits of maxillary expansion in Class III malocclusions, severely
constricted maxillae and patients with nasal deficiency. But this appliance also has
the potential for tissue damage and irritation to the patient.
In 1968 William Biederman(24) introduced his Hygienic rapid expander
(HYRAX). This appliance was designed similar to the Haas expander, but connected
the jackscrew to the dentition with a wire frame. The acrylic coverage of the palate

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had been removed in order to produce a more hygienic appliance. The Hyrax
appliance has been proven to be very effective regarding adolescent patients since
its introduction in the 1960’s and continues to be routinely used today.
Indications for RME(9, 10, 25-29)
 Cases with transverse discrepancy equal to or greater than 4mm.
 Patients who have lateral discrepancies that result in either unilateral or
bilateral posterior cross bites involving several teeth due to maxillary origin
and when maxillary molars are buccaly inclined to compensate for the
transverse skeletal discrepancy.
 Cleft lip and palate patients with collapsed maxillae are also RME candidates.
 Class II malocclusions: Elimination of inter-arch transverse dicrepancies prior
to orthopedic intervention in Class II malocclusions .
 Class III malocclusion of dental or skeletal origin. The correction of posterior
crossbites aids in forward growth of maxillary base and hence anterior
crossbites are also corrected in maxillary deficiency cases.
 SARPE (surgically assisted rapid palatal expansion). It is used in adult
skeletal posterior crossbites along with surgery.
 Constricted maxillary arches. involving airway impairment or mouth-
breathing tendencies.
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 angulation 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.

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Dentoskeletal effects of tooth-borneRME(9,10,25-31)

Rapid maxillary expansion occurs when the force applied to the teeth and the
maxillary alveolar processes exceeds the limits needed for orthodontic tooth
movement. The applied pressure acts as an orthopedic force that opens the
midpalatal suture. The appliance compresses the periodontal ligament, bends the
alveolar processes, tips the anchor teeth, and gradually opens the midpalatal suture.
A pyramidal opening of the suture is noted during RME.
When viewed from both the occlusal and frontal views, a larger opening will be
noted in the anterior region near the incisors, which progressively narrows
posteriorly. It was also noted that the procedure produced forward and downward
movement of the maxilla, downward and backward rotation of the mandible.

The skeletal and dental changes in three dimensions induced by RPE, in

adolescents was examined using cephalometric analysis of twenty children with
mean age 11.7 years who required RPE treatment. A Haas-type palatal expander was
used, the expander was activated with the rate of 2 turns per day (0.5mm) for 2 to 4
weeks, until the required expansion was achieved.
It was concluded that the maxilla was made to move slightly anterior with
downward displacement in addition to increased transverse measurements while the
mandible moved downward and backward leading to increase lower anterior face
height.

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The dentoskeletal effects of RME produced by the tooth tissue– borne and tooth-
borne expanders were compared and evaluated by means of CT scan. Eight girls
with unilateral or bilateral posterior crossbite, age ranged 11-14years, divided
equally into two groups, in both groups the same 7-mm screw was activated. CT
imaging was performed before expansion and after a three-month retention period
when the expander was removed.
It was concluded that, RME produced a significant increase in all measurements
of transverse dimensions, with decreasing magnitude from dental arch to basal bone
with similar orthopedic effects; this orthopedic change was one third of the
expansion screw. The expansion led to buccal movement of the maxillary posterior
teeth (tipping and bodily movements). The Hass expander produced a greater change
in the axial inclination of supporting teeth, especially in the first premolars,
compared with the Hyrax.
Lagravere el al (2005) conducted a systematic review to evaluate long-term
transverse, anteroposterior and vertical skeletal changes after rapid maxillary
expansion (RME). Clinical trials that assessed skeletal changes using cephalometric
analysis were the data to be collected. It was concluded that, the long-term stability
of transverse maxillary skeletal expansion was better in skeletally less mature
individuals (prepubertal growth peak) than skeletally more mature (pubertal and
postpubertal growth peak) individuals. This increase was approximately 25% of the
total appliance adjustment (dental expansion) in prepubertal adolescents but not
significant for postpubertal adolescents. RME did not produce significant
anteroposterior or vertical changes in the position of the maxilla and mandible.(30)

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INTRODUCTION OF SKELETLLY ANCHORED RME (32-42)

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.
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.
The mini-implant assisted rapid palatal expander (MARPE) is a simple
modification of the conventional RPE appliance; the main difference is the
incorporation of several mini-implants to ensure expansion of the underlying basal
bone and maintain the separated bones during the consolidation period. 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. Moreover, bone-borne palatal expanders have recently been
reported in several studies to have the capability to correct transverse maxillary
deficiency in adults, making it a potential alternative to surgically assisted RPE.
Bone-borne expanders have also been shown to prevent the dento-alveolar
tipping seen in adults when attempting to use traditional tooth-borne RPE
appliances. To avoid multiple surgeries, nonsurgical maxillary expansion can be
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performed to achieve both skeletal and dentoalveolar expansion for transverse

correction.

Mono-cortical versus 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.
Due to the increased magnitude of the applied force necessary to split the
interlocking suture in adult, a new approach to improve mini-implant stability during
bone-borne expansion is needed. Using bicortical mini-implant anchorage rather
than monocortical anchorage can improve mini-implant stability.
Moon et al(37) (2017) conducted a study using finite element analysis to evaluate
the effects of monocortical and bicortical mini-implant anchorage on bone-borne
palatal expansion. Two skull models were constructed to represent expansion before
and after midpalatal suture opening. Three clinical situations with varying mini-
implant insertion depths were studied in each skull model: monocortical, 1-mm
bicortical, and 2.5-mm bicortical.
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

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palatal expansion. However, the depth of bicortical mini-implant anchorage was not
significant.
RME in adult patients (35-37, 40-52)
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. The posterior teeth tip leading to poor occlusion and instability.
5. Tipping of the teeth or their subsequent relapse leads to clockwise
mandibular rotation, opening the bite and increasing facial height.
6. 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.
Ghoneima et al in a clinical study conducted using CBCT imaging in early
adolescents to determine whether the orthopedic forces of rapid maxillary expansion
using tooth borne appliance can produce significant quantitative changes in the
cranial and the circummaxillary sutures. They concluded that, the pterygopalatine
suture cannot be split when tooth borne palatal expanders are utilized.(38)
Surgically assisted RPE is the conventional treatment of choice to correct
transverse maxillary deficiency in adults. However, 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.

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A rigid element that delivers the expansion force directly to the basal bone could
be a solution for the previous problems. For this purpose, a mini-implant -assisted
rapid palatal expander (MARPE) has been designed.
Bone-borne palatal expanders have recently proved to have the capability to
correct transverse maxillary deficiency in adults, making it a potential alternative to
surgically assisted RPE. Bone-borne expanders have also been shown to prevent the
dento-alveolar tipping seen in adults when attempting to use traditional tooth-borne
RPE appliances.
Due to the increased magnitude of the applied force necessary to split the
interlocking suture in adult, a new approach to improve mini-implant stability during
bone-borne expansion is needed. Bi-cortical mini-implant anchorage has been
demonstrated in orthodontic tooth movement applications to be bio-mechanically
more favorable than mono-cortical anchorage for clinical situations requiring
heavy anchorage.
Lines (51) in 1975 conducted a study to evaluate the efficacy of rapid maxillary
expansion with corticotomy in adult patients. A corticotomy to weaken the maxillary
osseous structure for widening was employed in three nongrowing patients, after
which the maxillae were separated in the midline by the application of orthopedic
forces via a cemented rapid maxillary expansion device. The postoperative courses
were uneventful and gave no contraindication to the use of the corticotomy in adults.
The conclusion drawn was that, an expansion of the maxilla can be attained in
nongrowing patients following corticotomy.
In 2010, Lee et al(36) 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. This case report demonstrated the clinical effects in treating a
young adult with severe maxillary constriction using MARPE.
To avoid multiple surgeries, nonsurgical maxillary expansion was performed
with the MARPE to achieve both skeletal and dentoalveolar expansion for transverse
correction. Subsequent orthognathic surgery corrected the mandibular
prognathism and vertical excess. The stability of the expansion and the periodontal
status were favorable from the follow up clinical and radiologic findings.
Park et al(52) in 2017 conducted a retrospective study to evaluate the skeletal and
dentoalveolar changes after mini-implant assisted rapid palatal expansion in young
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adults. The study included 14 patients (mean age, 20.1 years; range, 16–26 years)
with maxillary transverse deficiency treated with MARPE. Skeletal and
dentoalveolar changes were evaluated using CBCT images acquired before and after
expansion.
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(40) 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. 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 perfectly parallel split of the
suture in the sagittal direction. The split of the midpalatal suture was asymmetrical
in the transverse direction; on average one half of ANS moved more than the
contralateral one by 1.1 mm.
The study showed that the pterygopalatine suture can be split by an orthopedic
appliance without the need of surgery in late adolescents; MSE was able to split the
pterygopalatine suture in its lower part in 53% of the sutures, as the pyramidal
process of the palatine bone was pulled out of the pterygoid notch of the pterygoid
process.
Moon et al(53) (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,
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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) using computational
fluid-structure interaction analysis. Three dimensional UA models fabricated from
cone beam computed tomography images obtained before (T0) and after (T1)
MARPE in an adult patient with OSAS were used for computational fluid dynamics
with fluid-structure interaction analysis. Seven and nine cross-sectional planes
(interplane distance of 10 mm) in the nasal cavity (NC) and pharynx, respectively,
were set along UA. Changes in the crosssectional area and changes in airflow
velocity and pressure, node displacement, and total resistance at maximum
inspiration (MI), rest, and maximum expiration (ME) were investigated at each plane
after MARPE.
It was concluded that; MARPE improves airflow and decreases resistance in UA;
therefore, it may be an effective treatment modality for adult patients with
moderate OSAS.
Retention & stability of after MARPE(30,31,40,54)
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 dvocated at least 3 month-retention period to stabilize the
expansion by using MSE appliance in a blocked manner.
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. Twenty-four patients (mean age, 21.6 years) who had
undergone MARPE and cone-beam computed tomography at T0, T1, and T2 were
included. Changes in the following parameters were compared using paired t-tests:
intercusp, interapex, alveolar, nasal floor, and nasal cavity widths; inclination of the
first molar (M1) and its alveolus; and thickness and height of the alveolar bone. A
linear mixed-effects model was used to determine variables that affected periodontal
changes in the M1.
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They concluded that; MARPE can be used as an effective tool for correcting
maxillomandibular transverse discrepancy, showing stable outcomes 1 year after
expansion.

Limitations of MARPE(52,53, 55)

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 is inevitable.
6. Limited evidence suggests 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.

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