International Orthodontics 2022; 20: 100657

Websites:
www.em-consulte.com
www.sciencedirect.com

Systematic Review
Interest of miniscrew-assisted rapid palatal
expansion on the upper airway in growing
patients: A systematic review

Simon Prévé, Beatriz García Alcázar

Available online: 23 June 2022 Centro odontológico de inovación y especialidades avanzadas, Dental School,
University Alfonso X El Sabio, Madrid, Spain

Correspondence:
Simon Prévé, Calle de Albarracín, 35, 28037 Madrid, Spain.
sprev@myuax.com

Keywords Summary
Pharyngeal airway
Nasal cavity Objective > This systematic review aimed to identify, evaluate, and provide an overview of the
Rapid palatal expansion available literature regarding the use of miniscrews in the rapid maxillary expansion (RME) on the
Rapid maxillary expansion upper airway.
MARPE Methods > The eligibility criteria were prospective trials that compared RME and miniscrew-
assisted rapid maxillary expansion (MARPE) regarding airways. A search of studies in Medline
(via PubMed), the Cochrane Library, Scopus and Scielo that measured the effects on the upper
airway was conducted until May 8, 2022. Two reviewers independently selected the studies,
extracted the data, and assessed the risk of bias for systematic reviews thanks to the Cochrane Risk
of Bias tool. Reporting of this review was based on the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines.
Results > Out of 160 potentially eligible studies, 7 were considered for systematic review. The
measurement of MARPE on airway was done with CBCT, rhinometry, and acoustic rhinomanometry.
In total, 344 patients were assessed. Two included studies showed high risk of bias and the rest
showed low to moderate risks of bias. Tooth-bone-borne RME significantly improved nasal airflow
[(Mean difference (MD) 52.7 cm3/s, 95% confidence interval (95% CI) (9.0–96.4), P = 0.020)],
reduced nasal resistance (MD 0.20 Pa/cm3, 95% (0.38–0.02), P = 0.028), Skeletal expansion at the
level of the nasal cavity was significantly greater in the MARPE group. The magnitude of the
expansion at the posterior level of the nasal cavity was almost two times higher in the tooth-bone-
borne group [(MD) 1.75 mm, 95% (1.16–2.35) and (MD) 0.78 mm, 95% (0.11–1.45), P < 0.001]
Conclusions > The short-term airflow changes after MARPE seems promising. Additionally, MARPE
is associated with greater skeletal maxillary expansion after retention, at various levels of the
nasal cavity, compared to conventional RME.

Introduction aetiology of posterior crossbite is multifactorial. Among others,

Transverse maxillary deficiency is a frequently observed condi- poor oral habits such as low tongue position, atypical swallow-
tion in the orthodontic patient, and is commonly presented in ing and altered breathing patterns due to adenoids and large
the form of unilateral or bilateral posterior crossbite [1]. The tonsils may contribute to the establishment of maxillary

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https://doi.org/10.1016/j.ortho.2022.100657
© 2022 The Authors. Published by Elsevier Masson SAS on behalf of CEO. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Prévé, B. García Alcázar
constriction, altered nasal breathing also have been associated
with maxillary transversal deficiency [2]. When a skeletal con-
stricted maxillary arch is diagnosed in adolescents, the rapid
maxillary expansion (RME) based on an orthopaedic action
which separates the two hemi-maxillaries at the level of the
median palatal suture is the treatment of choice [3]. It was
Angell [4] in 1860 who first described rapid maxillary expansion,
which was soon discredited, nevertheless since the 1960s it has
been one of the most widely used therapeutic instruments. It is
conventionally performed in the growing child by means of a
palatal expander which rests on the teeth (2 or 4 bands) and has
an expansion screw which is usually activated twice a day, i.e.,
0.5 mm per day [5], although obtaining an expansion of the
maxillary arch being mostly dental and less skeletal [6,7].
The advent of mini-screws over the last twenty years has offered
patients new treatment alternatives when conventional
approaches are limited. The idea of using a skeletal anchor
for RME is to be able to achieve greater skeletal expansion of
the maxilla through a greater opening of the mid-palatal suture
[8,9], thus since its arrival in our practice, questions have arisen
about the use of mini-screw assisted palatal expansion versus
conventional expansion devices. However, to date, there is only
one meta-analysis comparing their effects on the dimensions
and functions of the airway, but the latter included only 3 studies
making it worthwhile to complete [10].
The aim of our literature review is therefore to assess the value
of mini-screw assisted rapid palatal expansion on the upper
airway in comparison with conventional tooth/tissue anchored
devices in all studies published up until May 2022 in order to find
new indications for use in our practice.
Materials and methods
Protocol and registration
The present study was conducted and reported according to the
preferred reporting items for systematic reviews and meta-
analyses (PRISMA) guidelines [11] which were used to develop
a protocol that was submitted to PROSPERO database (ID:
331280).
All versions of the protocol are available at https://www.crd.
york.ac.uk/prospero.
Eligibility criteria
This systematic review was conducted to answer the question of
whether changes in expander design influence the outcome on
the upper airway. Only randomized controlled trials that com-
pared the effects of the MARPE with conventional RME on
airway in growing subjects were included.
Studies that combined the MARPE protocols with another treat-
ment (e.g., maxillary traction with a face mask), or that applied
the MARPE protocols using surgical procedures to assist in open-
ing the palatal suture were not included. In addition, studies that
evaluated patients with craniofacial development pathologies,
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clefts, and syndromes were excluded. Review articles, case
reports, case series, and expert opinions were not included in
this systematic review.
According to the Participants-Interventions-Comparisons-Out-
come-Study design (PICOS) strategy, randomized controlled
clinical trials on human patients were included if they met
the following selection criteria:
 Participants (P): patients of both sexes, without restriction of
age, socio-economic classification or ethnicity, who have been
diagnosed with maxillary transverse deficiency or posterior
crossbite.
 Intervention (I): MARPE.
 Comparison (C): conventional RME protocols anchored to the
teeth and/or mucosa without the use of mini-implants.
 Outcomes (O): changes in nasal cavity width, nasopharyngeal
volume or nasal flow and resistance.
 Study types (S): Randomized clinical trials.
Information sources, search strategy and selection
of studies
To find articles on the effects of maxillary bone-anchored and
hybrid expansion on the upper airway, the following four elec-
tronic databases were systematically searched: MEDLINE (via
PubMed), the Cochrane Library, Scopus, and Scielo.
To gather eligible studies, a search strategy was developed for
PubMed and other databases, matching MeSH terms according
to the following equation: ("Palatal Expansion Technique''
[MAJR] OR "maxillary expansion'' OR ((expand* OR expands*
OR distract*) AND (maxill* OR palat*))) AND (("bone-anchorage''
OR "bone-anchored'' OR "bone-borne'' OR "tooth-anchored'' OR
"tooth-borne'' OR "mini-implant'' OR "miniscrew'' OR "mini-
screw'' OR "mini-implant'' OR "skeletal anchorage'' OR "skele-
tally-anchored'' OR "hybrid'' OR "hybrid Hyrax'' OR "hybrid-
Hyrax'' OR "marpe'')) AND ("airway'' OR "airflow'' OR "nasal
width'' OR "nasal cavity'').
An initial screening of titles and abstracts was performed by two
separate readers (SP and BGA), to reduce the risk of individual
error, who independently selected all studies that met the
eligibility criteria. The same protocol was applied for the extrac-
tion of study characteristics (study design, setting, country,
patient number, sex, age, appliances, treatment duration, tim-
ing of follow-up, activation protocol, measurement method, and
outcome measured). In the case of abstracts that did not provide
sufficient information, the full texts were retrieved for analysis.
The final selection was made by reading the studies thoroughly,
again by both readers. In case of disagreement, each article was
reread and discussed with a third reviewer (INS) until consensus
was reached. The search was conducted until May 2022 and
included articles between 2001 and 2022. Apart from the filter
of human trials, no other filters for language, year of publication,
and status were applied.
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International Orthodontics 2022; 20: 100657
Assessment of the risk of bias in the included
studies
The reviewers independently assessed the included studies' risk
of bias using the tool described in the Cochrane Handbook for
Systematic Reviews of Interventions [12].
The risk of bias was assessed in the following six areas for each
study included:
 generation of random sequences (selection bias);
 allocation concealment (selection bias);
 blind evaluation of results (detection bias);
 incomplete data on outcomes (attrition bias);
 selective reporting (reporting bias);
 other biases.
The overall risk of bias was ranked in the following order:
Figure 1
PRISMA flow diagram depicting the selection of the eligible studies
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Systematic Review
 low risk of bias (plausible bias that is unlikely to seriously
affect the results) if all key areas have been assessed as having
a low risk of bias;
 unclear risk of bias (plausible bias that raises some doubt
about the results) if one or more key areas were assessed
as having an unclear risk of bias;
 high risk of bias (plausible bias that seriously undermines
confidence in the results) if one or more key areas have been
assessed as having a high risk of bias.
Results
Study selection
The flowchart of the research selection procedure, in accordance
with the PRISMA guideline, is presented in figure 1.
S. Prévé, B. García Alcázar

The electronic database search identified a total of 160 articles.
After eliminating 85 duplicates, a total of 75 studies were
screened by title and abstract to identify potentially eligible
articles. The selection led to the exclusion of 67 publications, and
the full texts of the remaining 8 articles were retrieved and
analysed according to the eligibility criteria. Subsequently, 1 arti-
cle was excluded after full text assessment because it was a
retrospective cohort study [13]. Finally, seven randomized con-
trolled trials were considered eligible for this systematic review
[14–20].
Study characteristics
All the selected studies (table I) were identified as randomized
controlled trials, all evaluated growing patients; three evaluated
prepubertal (adolescent) patients [15,17,18], and the other four
evaluated patients in the final stages of growth (late adoles-
cents) with a total of 344 subjects [14,16,19,20].
Regarding the design of conventional appliances; four studies
used expanders with four bands on the first premolars and first
molars [14,16,19,20], and three studies used expanders with
only two bands on the first upper molars [15,17,18]. The design
of the mini-screw devices varied from study to study. Although
Systematic Review
with some differences (design and number of mini-implants
used for anchorage), three studies achieved an exclusively
bone-supported expander [14,19,20], while the other four used
a hybrid dental and bone anchored expander [15–18].
One study investigated the influence of the expander design on
the airway function pre- and post-expansion with no follow up
[15]. The other studies compared the changes in the airway
dimension with measurements made post-expansion [17,20],
after 3 months for one study [20], after a 6 months period
[14,16,19], a year for 2 other studies [17,18] and Mehta's trial
even carried a follow up of 2 years and 8 months [19].
The tools used for airway assessment differed among the stud-
ies and included CBCT for linear measurements of the nasal
cavity width changes in five studies [16–19], acoustic rhinometry
was used in two others to evaluate the volume changes in the
nasal cavity [14,20], finally Bazargani et al. [15] assessed the
nasal airflow and resistance thanks to active anterior
rhinometry.
Risk of bias in studies
The risk of bias assessment is shown in figure 2. The Cochrane
risk of bias tool classified two studies as having a low risk of bias,

TABLE I
Summary of the qualitative analysis of the included studies in relation to study design, sample size, gender, age and type of palatal
expander.

Study Sample Observation period Tool Type of device

Kabalan et al. [14], Hyrax: n = 20, 14.1Y, 5M/15F T1 = pre-treatment AR 4 bands Hyrax expander vs.
2015, RCT (n = 61) MARPE: n = 20, 14.2Y; 8/13F T2 = 6 months CBCT 2 miniscrew bone-borne
Control: n = 21, 12.9Y, 6M/15F expander vs. control

Bazargani et al. [15], Hyrax: n = 19, 9.7Y, 11M/8F T0 = pre-treatment Rhinomanometry 2 bands Hyrax expander vs.
2018, RCT (n = 40) MARPE: n = 21, 10.2Y, 10M/11F T1 = post-expansion 2 bands and 2 miniscrews
hybrid Hyrax expander

Cheung et al. [16], Hyrax: n = 19, 13.8Y, 10M/9F T0 = pre-treatment CBCT 4 bands Hyrax expander vs.
2020, RCT (n = 51) MARPE: n = 19, 14.3Y, 8M/11F T1 = 6 months 2 bands and 2 miniscrews
Keyless: n = 13, 14.6Y, 2M/11F hybrid Hyrax expander vs.
keyless expander

Bazargani et al. [17], Hyrax: n = 26, 9.3Y, 13M/13F T0 = pre-treatment CBCT 2 bands Hyrax expander vs.
2021, RCT (n = 52) MARPE: n = 26, 9.5Y, 13M/13F T1 = post-expansion 2 bands and 2 miniscrews
T2 = 1 year hybrid Hyrax expander

Garib et al. [18], Hyrax: n = 14, 11.4Y, 8M/6F T1 = pre-treatment CBCT 2 bands Hyrax expander vs.
2021, RCT (n = 34) MARPE: n = 18, 10.8Y, 10M/8F T2 = 11 months 2 bands and 2 miniscrews
hybrid Hyrax expander

Mehta et al. [19], Hyrax: n = 21, 13.9Y T1 = pre-treatment CBCT 4 bands Hyrax expander vs.
2022, RCT (n = 60) MARPE: n = 20, 13.69Y T2 = 6 months 2 miniscrews bone-borne
Control: n = 19, 13.3Y T3 = 2Y and 8 months expander vs. control

Gokce et al. [20], Hyrax: n = 15, 12.8Y, 9M/6F T0 = pre-treatment AR 4 bands Hyrax expander vs.
2022, RCT (n = 46) Haas: n = 15, 12.5Y, 3M/12F T1 = post-expansion acrylic bonded Haas expander
MARPE: n = 16, 13.1Y, 3M/13F T2 = 3 months vs. 2 miniscrews bone-borne
expander

AR: acoustic rhinometry; C: control; CBCT: cone-beam computerized tomography; F: female; M: male; MARPE: mini-implant assisted maxillary expansion; Y: years.

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International Orthodontics 2022; 20: 100657
Figure 2
Risk of bias assessment for included randomized studies using the Cochrane Collaboration tool
three as having a moderate risk of bias, and two as having a
severe risk of bias. The main factors contributing to the risk of
bias were missing data and selectivity of outcomes, as well as
lack of information about the blindness of the assessors and
allocation concealment.
Results of individual studies
Regarding the strictly skeletally-anchored expander, Kabalan
et al. [14] found that even though the anatomical dimensions
and function of the airway parameters have been improved in
both hyrax and MARPE groups, the correlation between them
was not significant (P > 0.05). These results are in agreement
with those of Cheung et al.'s study [16], in which no significant
difference was found in this respect when comparing the hybrid
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Systematic Review
Hyrax and the tooth-borne expander. However, the study con-
cluded that the increase in total upper airway volume was
greater in prepubertal patients with MARPE, and in patients
who had the smallest volume at the beginning of the study.
Gokce et al. [20] tried to measure the volume changes in the
nasal cavity using acoustic rhinometry, secondary to tooth-borne
RME and bone-anchored RME. In their study, there were signifi-
cant increases in nasal volume in all groups after the treatment
(95%CI, P < 0.05) whereas in inter-group comparisons the
changes were found to be similar (95%CI, P > 0.05). However,
Mehta et al. [19] found that in the long term, purely bone-
supported RME resulted in a significantly greater increase in
nasal width at the anterior and posterior parts of the nasal cavity
respectively of 1.75 mm (95%CI: 1.16–2.35, P < 0.001) and
S. Prévé, B. García Alcázar

Systematic Review
TABLE II
Characteristics of included studies with respect to follow-up and outcomes.

Study Measurement Parameters Value Significance

3
Kabalan et al. [14], Nasal cavity volume changes: Right Vol1 T1T2 before/after Right: 0.03, 1.27/0.38, 1 mm P > 0.05
(2015) _Bone Expander group Lt Vol1 (mm3) T1T2 before/ Left: 0.24, 1.4/0.06, 1.4 mm3
between T1 and T2 after Right: 0.15, 1.64/ 0.19, 1.89 mm3
_Tooth Expander group (Mean, SD) Left: 0.19, 1.69/0.07, 1.75 mm3
between T1 and T2 Right Vol1 (mm3) T1T2
before/after
Lt Vol1 T1T2 before/after
(Mean, SD)
Bazargani et al. [15], Nasal airflow and resistance: Nasal airflow cm3/s Complete cases: 51.0 (9.6 to 92.5) P = 0.018*,
(2018) Mean difference between Mean difference (95% CI) Multiple imputation: 52.7 (9.0 to 96.4) P = 0.020*,
Hyrax and Hybrid groups Nasal Resistance Pa s/cm3 Complete cases: 0.21 (0.4 to 0.04) P = 0.016*,
Mean difference (95% CI) Multiple imputation: 0.20 (0.4 to 0.02) P = 0.028*

Cheung et al. [16], Nasal cavity volume changes: Nasal cavity volume (mm3) 1066.1 (8793.0) P = 0.32
(2020) _Hyrax group between T1 and T1–T0—mean (SD) 2688.7 (3377.0)
T0 Nasal cavity volume (mm3) 1276.4 (5554.6)
_Hybrid Hyrax group between T1–T0—mean (SD)
T1 and T0 Nasal cavity volume (mm3)
_Keles group between T1 and T1–T0—mean (SD)
T0
Bazargani et al. [17], Nasal cavity width changes: P1/N1width (mm) T2-T0 1.1 (0.1 to 2.1) P = 0.025*,
(2021) Mean difference between Mean difference (95% CI) 1.2 (0.4 to 2.0) P = 0.0005*,
MARPE and Hyrax groups T2- P1/N2 width (mm) T2-T0 1.1 (0.1 to 2.0) P = 0.023*
T0 Mean difference (95% CI) 0.8 ( 0.2 to 1.8) P = 0.13
P2/N1 width (mm) T2-T0
Mean difference (95% CI)
P2/N2 width (mm) T2-T0
Mean difference (95% CI)
Garib et al. [18], Nasal cavity width changes: Nasal cavity width (mm) 1.15 (0.4 to 1.99) P = 0.004*
(2021) Mean difference between T2-T1
hybrid and hyrax groups T2-T1 Mean difference (95% CI)
Mehta et al. [19], Nasal cavity width changes: PNCW (mm) T3-T1 MARPE 1.75 (1.16, 2.35) P < 0.001*,
(2022) _MARPE group between T3-T1 Mean difference (95% CI) 1.15 (0.63, 1.67) P = 0.017*,
_Hyrax group between T3-T1 ANCW (mm) T3-T1 MARPE 0.78 (0.11, 1.45) P < 0.001*,
Mean difference (95% CI) 0.93 (0.08, 1.78) P = 0.001*
PNCW (mm) Hyrax T3-T1
Mean difference (95% CI)
ANCW (mm) T3-T1 Hyrax
Mean difference (95% CI)
Gokce et al. [20], Nasal cavity volume changes: Nasal cavity volume Hyrax: 1.86 (0.91–2.81) P > 0.05
(2022) _Hyrax group between T2 and changes T2-T0 (mm3) TTB: 1.16 (0.26–2.05)
T1 Mean difference (95% CI) Bone-borne: 2.52 (1.32–3.71)
_Bone-borne group between
T2 and T1
_TTB group between T2 and
T1

ANCW: anterior nasal cavity width; CI: confidence interval; Lt: left nasal orifices; N1: nasal width at the most inferior part of cavum nasi distance; N2: nasal width at the widest part of
cavum nasi; P1: apex first premolar; P2: apex first molar palatal root; PNCW: posterior cavity width; Rt: right nasal orifices; SD: standard deviation; TB: tooth-tissue-borne; Vol:
volume; Vol1: mean change in nasal cavity volume from front of the nose; Vol2: mean change in nasal cavity volume to the minimum cross-sectional areas. Before and after refer to
use of nasal decongestant.
*
Statistically significant (P < .05).

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International Orthodontics 2022; 20: 100657
1.15 mm (95%CI: 0.63–1.67, P = 0.017) compared to the tradi-
tional RME and control groups in a 2 years and 8 months follow
up period.
On the other hand, four studies compared the conventional
hyrax expander with a hybrid teeth-bone-borne appliance, with
regard to the increase in the width of the nasal cavity, two
studies found significant results (P < 0.05) demonstrating the
superiority of the hybrid expander over the Hyrax model in
increasing the width of the nasal cavity [17,18]. Moreover
Cheung et al. [16] found that the changes in the nasal cavity
volume were more than twice greater in the tooth-bone borne
group but this result was not significant (P = 0.32). Furthermore,
Bazargani et al. [15], found that MARPE induced significantly
higher nasal air flow values ((MD 52.7 cm3/s, (95%CI: 9.0–
96.4), P = 0.020)) than Hyrax and significantly lower nasal
resistance values (MD 0.20 Pa s/cm3, 95%CI: 0.38–0.02,
P = 0.028) in favour of the MARPE group.
A brief description of the included and evaluated studies is
presented in tables I and II.
Discussion
Summary of evidence
This systematic review summarizes and critically appraises the
evidence from randomized clinical trials that featured
344 patients on the potential upper airway benefits of MARPE
over conventional RME. Although hybrid and strictly bone-
anchored expanders were first described more than a decade
ago [21,22], research comparing the two conceptions has been
remarkably limited, and the results have often not coincided.
It is known that the width of the nasal cavity and its volume
increases after expansion through the intermaxillary suture,
however, the clinical implication is not clearly quantified [23–
30]. Three of the included studies converged on the fact that
conventional RME and MARPE resulted in significant expansion
of the nasal cavity, albeit more so with bone anchorage [17–19].
Bazargani et al. [17] compared the dentoalveolar and skeletal
effects of dental and hybrid expanders in patients aged 9.3 to
9.5 years with a one-year follow-up. He concluded that skeletal
expansion at the mid-palatal suture was significantly greater in
the hybrid group, but may not be clinically significant. The
author also stated that the Hyrax expander worked well in
young preadolescents, but that the hybrid expander may be
more effective in cases of upper airway obstruction. These data
are consistent with the results of Garibs et al.'s [18] trial which
reported a two-fold increase in nasal cavity width in the MARPE
group (2.26 mm) compared to the hyrax group (1.11 mm) even
though this result contrasts with Toklu et al. [31] study which
findings showed higher values for the conventional RME with an
increased width of the nasal cavity ranging from 1.2 to 2.73 mm.
Regarding volume changes of the nasal cavity, even though
their results are not statistically significant both Cheung et al.
[16] and Gokce et al. [22] found the MARPE designs to be
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superior than the traditional hyrax, as shown in previous retro-
spective studies [13,32]. Although it has been shown that RME
in general can increase upper airway volume [33] the effect of
this increase on improved breathing or quality of life is unclear. It
should be noted here that, based on the current evidence, no
recommendation can be made for the use of any type of MARPE
for the treatment of ventilatory disorders.
Data from a clinical trial included in this review indicate that RME
with a hybrid expander was associated with higher nasal airflow
and lower nasal airway resistance compared to conventional
RME [15]. It has been reported in the literature that the average
total nasal resistance in normal subjects after decongestion is
between 0.15 and 0.5 Pa s/cm3 [34]. Therefore, the reduction in
nasal airway resistance of 0.21 Pa s/cm3 shown by Bazargani
et al. [15] in favour of MARPE could be considered close to the
decongestant effect of a nasal spray, which certainly looks
promising, for example, in children with nasal airway
obstruction.
Comparing the RME with hybrid or traditional expanders and the
control group, Mehta et al. [19] found that in the short term,
both showed similar expansion, but at long-term follow-up of
2 years and 8 months, the bone-supported expander produced a
significant increase in palatal width compared to the conven-
tional RME and control groups. In this study, the mean age was
over 13 years. It is known that RME is more effective in younger
patients, as demonstrated in Cheung's study where he found a
greater increase in total upper airway volume in prepubertal
patients (cervical vertebral maturation stage 1–3) than in
patients past peak growth, and MARPE produced a greater
increase than the Hyrax appliance in this category of subjects,
however, the study found no significant difference in the vol-
ume changes of the three compartments of the upper airway
between MARPE and conventional expansion [16] which is in
agreement with Abu Arqub et al.'s [10] systematic review.
Limitations
The data from the studies were very heterogeneous, selecting
articles that met the eligibility criteria was difficult, and signifi-
cant differences were found in the age of the patients, follow-up
duration, and design of the devices used.
In addition, the lack of information on baseline dysmorphia or
activation protocols makes interpretation and generalisability of
the observed results subject to caution.
Conclusions
Within the limits of the current evidence from randomized trials,
this qualitative systematic review indicated that MARPE is asso-
ciated with greater maxillary skeletal expansion at the palatal
suture and nasal cavity width after retention compared to
conventional RME.
S. Prévé, B. García Alcázar
A significant increase in nasal airflow and a reduction in airway
resistance appears to be associated with the hybrid expander
immediately after expansion.
Author contributions: Simon Prévé carried out the conception and design
of the study, carried out the acquisition of data, the analysis and
interpretation of data, and drafted the article.
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