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Short-term and long-term effects of miniscrew-assisted and conventional

rapid palatal expansion on the cranial and circummaxillary sutures

Article  in  American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American
Board of Orthodontics · February 2023
DOI: 10.1016/j.ajodo.2023.01.007

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ORIGINAL ARTICLE

Short-term and long-term effects of

miniscrew-assisted and conventional
rapid palatal expansion on the cranial
and circummaxillary sutures
Ahmad Ahmida,a Shivam Mehta,b Edward Amelemah,c Rehana Bashir,d Manuel Lagrave
re Vich,e
Aditya Tadinada,f Veerasathpurush Allareddy,g and Sumit Yadavd
San Antonio, Tex, Milwaukee, Wis, Farmington, Conn, Edmonton, Alberta, Canada, and Chicago, Ill

Introduction: The objective of this study was to analyze the short-term and long-term effects of miniscrew-
assisted rapid palatal expansion (MARPE) and conventional rapid palatal expansion (RPE) appliances on
cranial and circummaxillary sutures as compared with a matched control group. Methods: One hundred and
eighty cone-beam computed tomography scans for 60 subjects were evaluated for the 3 groups: (1) MARPE
(n 5 20; aged 13.7 6 1.74 years), (2) RPE (n 5 21; age 13.9 6 1.14 years), and (3) control (n 5 19; age
13.3 6 1.49 years) at pretreatment (T1), postexpansion (T2), and posttreatment (T3) (T1 to T3: MARPE, 2
years 8 months; RPE, 2 years 9 months; control, 2 years 7 months). Frontonasal suture, frontomaxillary
suture, zygomaticomaxillary suture, zygomaticofrontal suture, intermaxillary suture, pterygomaxillary suture,
nasomaxillary suture, and zygomaticotemporal suture were measured on the right and left sides for all 3 time
labels. In addition, midpalatal suture was measured at the incisor, canine, and molar levels. Results: Within-
group analysis showed that MARPE and RPE led to a significant increase in the widths of frontonasal, fronto-
maxillary, intermaxillary, nasomaxillary, and midpalatal suture at incisor, canine, and molar levels at T2
compared with T1. Between-group analysis showed that MARPE and RPE significantly increased the width
of the intermaxillary and midpalatal suture at the incisor, canine, and molar compared with controls at T2. In
the long term, between-group comparisons showed no significant difference among the 3 groups except that
MARPE led to a significant increase in the width of midpalatal suture at incisor, canine, and molar levels
compared with RPE and controls at T3. Conclusions: MARPE led to a significant increase in the width of the
midpalatal suture at incisor, canine, and molar levels compared with RPE and controls in the long term. There
was no difference in the width of other cranial and circummaxillary sutures among the 3 groups in the long term.
(Am J Orthod Dentofacial Orthop 2023;-:e1-e12)

T
ransverse maxillary deficiency leads to maxillo- 8%-23% of the population.1,2 Rapid palatal expansion
mandibular discrepancies resulting in posterior (RPE) is a technique for managing posterior crossbite
crossbites. Posterior crossbites are prevalent in and uses an expansion jack-screw anchored to the
a
maxillary posterior teeth. When the expander screw is
Jefferson Dental and Orthodontics, San Antonio, Tex.
b
Department of Developmental Sciences and Orthodontics, School of Dentistry, activated, a transverse force is applied to the maxilla,
Marquette University, Milwaukee, Wis. maxillary teeth, and associated hard and soft tissues.
c
School of Dental Medicine, University of Connecticut, Farmington, Conn. The right and left maxilla fuse with each other at midpa-
d
Division of Orthodontics, University of Connecticut Health, Farmington, Conn.
e
Division of Orthodontics, University of Alberta, Edmonton, Alberta, Canada. latal sutures. Applying transverse force with expanders
f
Division of Oral and Maxillofacial Radiology, University of Connecticut Health, leads to the midpalatal suture opening and other cir-
Farmington, Conn. cummaxillary sutures. In addition, the palatal expansion
g
Department of Orthodontics, University of Illinois at Chicago, Chicago, Ill.
All authors have completed and submitted the ICMJE Form for Disclosure of Po- also leads to compression of the periodontal ligament
tential Conflicts of Interest, and none were reported. and bending of the alveolar process. However, RPE can
Address correspondence to: Shivam Mehta, Department of Developmental Sci- lead to certain side effects, such as root resorption,
ences and Orthodontics, School of Denistry, Marquette University, 1801 W Wis-
consin Ave, Milwaukee, WI 53233; e-mail, shivam.mehta@marquette.edu. buccal dehiscence, fenestration, buccal tipping, and so
Submitted, September 2022; revised and accepted, January 2023. on.3,4
0889-5406/$36.00 Miniscrew-assisted rapid palatal expansion (MARPE)
Ó 2023 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2023.01.007 is a relatively new method introduced to counter the side

e1
e2
effects associated with RPE.5,6 MARPE appliance con-
sists of an expansion screw anchored to miniscrews
(mini-implants) inserted into the palate. Different de-
signs for MARPE can be constructed, such as with 2 or
4 miniscrews.7-9 The rationale of using the MARPE
appliance is to obtain a higher orthopedic maxilla
expansion with minimal side effects as the forces are
not directed to the teeth but to the bone with the help
of miniscrews.
The main purpose of palatal expansion (RPE or
MARPE) is to correct the transverse maxillomandibular
discrepancies. However, the effects of palatal expansion
are not restricted only to the teeth but are also felt in the
adjacent structures.10 Each maxilla articulates with 9
bones in the craniofacial skeleton by cranial and circum-
maxillary sutures. These structures of the face and cra-
nium may also experience some effects from the
palatal expansion. The sutures in the craniofacial region
have multiple functions. The role of the suture is not
limited to only connecting the bones but also absorbing
forces, acting as growth sites, and permitting minor
movement between the bones.11-14 It has been
reported that sutures can be affected by applying
orthopedic forces in animal studies.15-20 When sutures
are experimentally separated in animals, an increased
skeletal remodeling is observed, and the extent of
remodeling is reported to be proportional to the
suture’s distance from the applied force. However,
there is an intrinsic difference in the morphology of
sutures, maturation of sutures, and sequence of
closure of the suture in animal species and humans.
Therefore, such results cannot be directly applied to
clinical situations.
Palatal expansion applies a high magnitude of forces
to the maxilla, transmitted as compressive strains on the
craniofacial structures. The circummaxillary sutures
which absorb and transmit these forces are also modified
by these forces.21 Accordingly, it has been observed that
RPE leads to significant alterations in craniofacial struc-
tural morphology.22 In a study using human skulls for
assessing the effects of rapid palatal expansion, Kudlick
et al23 showed that all the bones that articulate with the
maxilla are significantly displaced by rapid palatal
expansion. Therefore, it becomes important to analyze
the effects of palatal expansion on the cranial and cir-
cummaxillary sutures. However, literature on the effects
of palatal expansion appliances on cranial and circum-
maxillary sutures is scarce. Although the effects of RPE
have been evaluated, the effects of MARPE on cranio-
maxillary sutures have not been investigated
adequately.24 In addition, previous studies have investi-
gated the short-term effects of RPE, but the long-term
effects are still unknown. Because of the inadequate
- 2023  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
Ahmida et al
follow-up period after expansion and the lack of con-
trols in the current literature, it is difficult to have mean-
ingful conclusions that can be applied clinically.
Cone-beam computed tomography (CBCT) allows
the 3-dimensional (3D) visualization of the craniofa-
cial morphology in different views with the help of
multiplanar reconstruction. Therefore, compared with
a matched control group, this study was undertaken
to evaluate the short-term and long-term effects of
MARPE and RPE on cranial and circummaxillary su-
tures using CBCT. Our null hypothesis was that there
is no difference in the width of cranial and circum-
maxillary sutures in the short and long term among
the MARPE, RPE, and controls.
MATERIAL AND METHODS
The Institutional Review Board at the University of
Connecticut approved the current study for a retrospec-
tive evaluation of the CBCT scans (Institutional Review
Board: SM 1168). All the patients were a part of a ran-
domized controlled clinical trial and treated in the
same orthodontic setting at the University of Alberta.
The patients were divided into 3 groups (1) MARPE, (2)
RPE, and (3) control. The criteria for inclusion were pa-
tients aged 11-15 years with bilateral maxillary crossbite
without any prior orthodontic intervention, absence of
adenoidectomy, absence of tonsillectomy, absence of
any craniofacial syndromes, no history of bone disorders,
and absence of temporomandibular joint disorder. The
MARPE received the bone-anchored expansion appli-
ance, designed with 2 miniscrews of 12.0 3 1.5 mm
(Straumann GBR System, Andover, Mass) inserted into
the maxillary palate, 1 on each side of the midpalatal su-
ture (Fig 1, A). The RPE group received the tooth-
anchored expansion appliance soldered to the bands
on the maxillary first premolars and first molars (Fig 1,
B). The activation of the appliances was done by opening
the expansion screw by 2 turns/d (1 turn 5 0.25 mm).
CBCT scans were recorded for 3-time labels for all 3
groups with the protocol (120 kV, 20 mA, 0.3 voxels,
and 8.9 seconds) and with the same equipment (iCAT
Imaging Sciences International, Hartfield, Pa). The first
time label was the pretreatment or initial CBCT for all
3 groups (T1). The second time label was the postexpan-
sion CBCT for MARPE and RPE groups and 6 months af-
ter the initial for the control group (T2). The control
group did not receive any treatment from T1 to T2,
and all 3 groups were bonded with a preadjusted edge-
wise appliance at T2. The third time label was the post-
treatment CBCT for all 3 groups (T3). The average
treatment time from T1 to T3 was 2 years 8 months
for MARPE, 2 years 9 months for RPE, and 2 years 7
Ahmida et al
Fig 1. Design of appliances: A, MARPE; B, RPE appliance. MARPE, miniscrew-assisted rapid palatal
expansion.
months for controls. The average age of patients in the
MARPE group (20 patients; 7 males, 13 females) was
13.7 6 1.74 years, the RPE group (21 patients; 6 males,
15 females) was 13.9 6 1.14 years, and the control
group years (19 patients; 5 males, 14 females) was
13.3 6 1.49 years. The patients were informed about
the radiation exposure with CBCT. The potential risks
from radiation exposure with recorded CBCT scans
were minimal. For the CBCT scans, the radiation dosage
could be as low as 50 mSv,25 and the yearly limit of the
effective dose for infrequent radiation exposure is 5
mSv.26
CBCT scans (n 5 180) were analyzed for 60 patients
at the 3-time labels. The CBCT data were reconstructed
using digital imaging and communication in medicine
data with the Dolphin Imaging software (version 11.9;
Dolphin Imaging and Management Solutions, Chats-
worth, Calif). Three CBCTs were discarded because of
motion artifacts. The orientation of the CBCT scans
was standardized by aligning the CBCT scans to the
Frankfort horizontal plane, skeletal midline, and line
through the deepest part of the lateral aspects of the
zygomatic bone. The cranial and circummaxillary su-
tures were located, and their width was measured by
identifying the greatest width of the suture on axial, cor-
onal, and sagittal sections of the CBCT scan according to
the orientation of the suture. The location of each suture
was established by referencing the corresponding loca-
tion in the 3D volume of the CBCT scan by moving the
cursor at the same reference area for different time la-
bels. Coronal sections measured the frontonasal, fronto-
maxillary, zygomaticofrontal, zygomaticomaxillary, and
intermaxillary sutures (Figs 2, A-D and 3, A). Sagittal
sections were used to measure the pterygomaxillary su-
ture and nasomaxillary sutures (Figs 3, B and C). Axial
sections were used to measure the zygomaticotemporal
and midpalatal sutures (Figs 4, A and B). The midpalatal
suture width was analyzed at the level of maxillary inci-
sors, canines, and first molars. All the measurements
American Journal of Orthodontics and Dentofacial Orthopedics
e3
were recorded by a single investigator (A.A.). Sixty
CBCT scans were measured again by the same investi-
gator and another investigator for intrarater and inter-
rater reliability (A.A. and E.A.).
Statistical analysis
It was determined that using an analysis of variance,
19 samples per group would allow us to detect a 0.8 stan-
dard deviation mean difference in change from T1 to T3
for 80% power at the 5% significance level. The
normality of the distribution of data was analyzed using
the Shapiro-Wilk test and a quantile-quantile plot. The
data were found to be normally distributed. The descrip-
tive statistics were summarized for MARPE, RPE, and
control groups. The mean difference from T1 to T2 and
T1 to T3 was tested against no change within groups
by paired t test. All the statistical analyses were performed
in Graphpad Prism (version 9; GraphPad Software, La
Jolla, Calif). P values \5% were considered statistically
significant. In addition, Tukey’s Honest Significant Dif-
ference method adjusted P values for multiple testing.
The intraclass correlation coefficient and Dahlberg’s for-
mula were used to assess the method error.
RESULTS
The interrater and intrarater reliability shows that the
measurements indicated good reliability for all parame-
ters, with the intraclass correlation values .0.935.
In the short term (T1 vs T2), both MARPE and RPE led
to a statistically significant increase in the width of fron-
tonasal suture, frontomaxillary suture, intermaxillary su-
ture, and nasomaxillary suture on the right and left sides
(P \0.05; Tables I and II). In addition, a significant in-
crease was observed in the width of the midpalatal su-
ture at the incisor, canine, and molar with both
MARPE and RPE after expansion (P \0.05; Tables I
and II). In the control group, there was no significant
change in the width of circummaxillary sutures except
- 2023  Vol -  Issue -
e4 Ahmida et al

Fig 2. Coronal CBCT sections: A, Frontonasal suture; B, Frontomaxillary suture; C, Zygomaticomax-

illary suture; D, Zygomaticofrontal suture. CBCT, cone-beam computed tomography.

the width of the intermaxillary suture, which decreased
from T1 to T2 (P \0.05; Table III).
In the long term, there was no significant change in
the width of the sutures in the MARPE group except
the intermaxillary suture and the midpalatal suture at
incisor, canine, and molar, which was observed to be
significantly increased at T3 compared with T1
(P \0.05; Table I). In the RPE and the control group,
the width of the pterygomaxillary suture on the left
side decreased significantly at T3 compared with T1
(P \0.05; Tables II and III). In addition, in the control
group, the width of the zygomaticofrontal suture and
frontonasal suture decreased significantly bilaterally at
T3 compared with T1 (P \0.05; Table III)
There was no significant difference among MARPE,
RPE, and control groups at T1 (Table IV). When observed
at T2, MARPE and RPE led to a significant increase in the
width of the intermaxillary suture compared with

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Ahmida et al e5

Fig 3. A, Coronal CBCT section showing intermaxillary suture, with sagittal CBCT section showing; B,
Pterygomaxillary suture; C, Nasomaxillary suture. CBCT, cone-beam computed tomography.

Fig 4. Axial CBCT sections: A, Zygomaticotemporal suture; B, Midpalatal suture. CBCT, cone-beam
computed tomography.

controls at T2 (P \0.05; Table V). In addition, the width DISCUSSION

of the midpalatal suture at the incisor, canine, and molar
increased significantly in MARPE and RPE groups
compared with controls at T2 (P \0.05; Table V).
In the long term, there was no significant difference
in any parameters among the RPE and control groups
(Table VI). The width of the midpalatal suture was signif-
icantly increased at the incisor, canine, and molar in
MARPE compared with RPE and controls when observed
at T3 (P \0.05; Table VI).
This study assessed and compared the long-term ef-
fects of MARPE and RPE on cranial and circummaxillary
sutures with controls. Our null hypothesis was rejected as
MARPE showed a significantly increased midpalatal su-
ture width at the incisor, canine, and molar compared
with RPE and controls in the long term. However, no
other differences were found among the 3 groups in
the width of the other cranial and circummaxillary su-
tures. Rapid maxillary expansion results in heavy forces

American Journal of Orthodontics and Dentofacial Orthopedics - 2023  Vol -  Issue -

e6 Ahmida et al

Table I. Parameters for the MARPE group at T1, T2, and T3

P value P value
Parameters T1 T2 T3 T2 T1 T3 T1 (T2 vs T1) (T3 vs T1)
Frontonasal suture 0.70 6 0.26 1.00 6 0.54 0.68 6 0.29 0.30 (0.06-0.54) 0.03 ( 0.17 to 0.12) 0.017* 0.694
right (mm)
Frontonasal suture 0.69 6 0.26 0.82 6 0.21 0.67 6 0.28 0.12 (0.02-0.22) 0.04 ( 0.18 to 0.10) 0.025* 0.562
left (mm)
Frontomaxillary suture 0.61 6 0.21 0.69 6 0.19 0.53 6 0.28 0.09 (0.02-0.16) 0.07 ( 0.23 to 0.09) 0.015* 0.354
right (mm)
Frontomaxillary suture 0.58 6 0.20 0.67 6 0.19 0.56 6 0.29 0.09 (0.01-0.17) 0.03 ( 0.19 to 0.13) 0.028* 0.666
left (mm)
Zygomaticomaxillary 0.63 6 0.18 0.71 6 0.21 0.71 6 0.23 0.08 ( 0.02 to 0.18) 0.08 ( 0.02 to 0.19) 0.109 0.110
suture right (mm)
Zygomaticomaxillary 0.69 6 0.24 0.78 6 0.26 0.79 6 0.16 0.09 ( 0.04 to 0.22) 0.10 ( 0.03 to 0.23) 0.173 0.129
suture left (mm)
Zygomaticofrontal 0.78 6 0.21 0.85 6 0.18 0.82 6 0.17 0.07 ( 0.09 to 0.22) 0.04 ( 0.07 to 0.16) 0.368 0.415
suture right (mm)
Zygomaticofrontal 0.83 6 0.20 0.85 6 0.17 0.83 6 0.18 0.02 ( 0.11 to 0.16) 0.01( 0.11 to 0.13) 0.745 0.843
suture left (mm)
Intermaxillary suture 0.62 6 0.23 0.89 6 0.14 0.766 0.19 0.27 (0.15-0.40) 0.18 (0.02-0.34) \0.001* 0.031*
(mm)
Pterygomaxillary 0.65 6 0.13 0.61 6 0.21 0.58 6 0.12 0.04 ( 0.13 to 0.06) 0.07 ( 0.16 to 0.03) 0.421 0.163
suture right (mm)
Pterygomaxillary 0.60 6 0.12 0.62 6 0.20 0.57 6 0.11 0.02 ( 0.08 to 0.12) 0.03 ( 0.12 to 0.06) 0.671 0.438
suture left (mm)
Nasomaxillary suture 0.63 6 0.25 0.73 6 0.16 0.66 6 0.18 0.10 (0.00-0.20) 0.07 ( 0.06 to 0.21) 0.048* 0.272
right (mm)
Nasomaxillary suture 0.64 6 0.25 0.75 6 0.21 0.67 6 0.13 0.11 (0.01-0.20) 0.05 ( 0.09 to 0.19) 0.029* 0.448
left (mm)
Zygomaticotemporal 0.55 6 0.10 0.60 6 0.15 0.59 6 0.11 0.05 ( 0.02 to 0.12) 0.06 ( 0.01 to 0.14) 0.176 0.102
suture right (mm)
Zygomaticotemporal 0.53 6 0.09 0.61 6 0.20 0.59 6 0.17 0.08 ( 0.02 to 0.18) 0.07 ( 0.02 to 0.16) 0.105 0.114
suture left (mm)
Midpalatal suture 0.55 6 0.18 1.09 6 0.60 0.69 6 0.21 0.54 (0.24-0.85) 0.12 (0.02-0.21) 0.002* 0.019*
incisor (mm)
Midpalatal suture 0.56 6 0.17 1.09 6 0.67 0.71 6 0.11 0.53 (0.21-0.84) 0.12 (0.03-0.20) 0.002* 0.008*
canine (mm)
Midpalatal suture 0.63 6 0.19 1.13 6 0.39 1.00 6 0.21 0.50 (0.32-0.68) 0.37 (0.26-0.49) \0.001* \0.001*
molar (mm)
Note. Values are mean 6 standard deviation or mean (95% CI).
MARPE, miniscrew-assisted rapid palatal expansion.
*Statistically significant at P \0.05.

on the maxillary arch and surrounding structures in the
range of 16,000-20,000 g of force.27 This can result in
changes in the width of the cranial and circummaxillary
sutures. Because of the large magnitude of forces ex-
erted by the expansion appliances, researchers have tried
to evaluate the effects of such palatal expansion on the
cranial and circummaxillary sutures.24,28 However,
because of limitations such as 2-dimensional assess-
ment, absence of MARPE, short follow-up, and lack of
controls, the long-term effects of palatal expansion ap-
pliances on the cranial and circummaxillary sutures are
still not known. Therefore, this study was undertaken
to identify evidence for clinicians regarding the long-
term effects of expansion appliances on cranial and cir-
cummaxillary sutures.
A significant increase was observed in the width of
the frontonasal suture, frontomaxillary suture, inter-
maxillary suture, and nasomaxillary suture with both
RPE and MARPE at T2. These results concur with previ-
ous studies indicating that these areas are affected by
the forces generated by palatal expansion.22,29-37 A
previous study has shown that significant stresses are
observed at the frontonasal suture after RPE.30 MARPE
appliance is similar to RPE in design, the only difference
being that MARPE appliance is anchored to the palatal
bone with miniscrews.9 MARPE also applies transverse

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Ahmida et al e7

Table II. Parameters for the RPE group at T1, T2, and T3
P value P value
Parameters T1 T2 T3 T2 T1 T3 T1 (T2 vs T1) (T3 vs T1)
Frontonasal suture 0.74 6 0.18 0.82 6 0.20 0.66 6 0.13 0.08 (0.01-0.15) 0.08 ( 0.19 to 0.04) 0.026* 0.176
right (mm)
Frontonasal suture 0.73 6 0.21 0.81 6 0.21 0.61 6 0.14 0.09 (0.01-0.17) 0.11 ( 0.24 to 0.02) 0.038* 0.084
left (mm)
Frontomaxillary suture 0.62 6 0.15 0.71 6 0.13 0.53 6 0.10 0.09 (0.01-0.16) 0.09 ( 0.19 to 0.00) 0.025* 0.060
right (mm)
Frontomaxillary suture 0.66 6 0.15 0.73 6 0.14 0.59 6 0.17 0.08 (0.01-0.14) 0.07 ( 0.15 to 0.00) 0.022* 0.062
left (mm)
Zygomaticomaxillary 0.54 6 0.35 0.63 6 0.36 0.66 6 0.21 0.09 ( 0.04 to 0.21) 0.11 ( 0.06 to 0.28) 0.170 0.179
suture right (mm)
Zygomaticomaxillary 0.50 6 0.36 0.64 6 0.31 0.63 6 0.23 0.14 ( 0.04 to 0.32) 0.12 ( 0.01 to 0.25) 0.130 0.070
suture left (mm)
Zygomaticofrontal 0.80 6 0.21 0.70 6 0.25 0.73 6 0.17 0.09 ( 0.20 to 0.02) 0.09 ( 0.19 to 0.02) 0.103 0.091
suture right (mm)
Zygomaticofrontal 0.81 6 0.18 0.74 6 0.23 0.76 6 0.18 0.07 ( 0.15 to 0.01) 0.07 ( 0.16 to 0.01) 0.087 0.074
suture left (mm)
Intermaxillary suture 0.63 6 0.35 1.02 6 0.64 0.71 6 0.60 0.39 (0.03-0.74) 0.14 ( 0.19 to 0.47) 0.036* 0.375
(mm)
Pterygomaxillary 0.62 6 0.18 0.60 6 0.13 0.55 6 0.11 0.02 ( 0.11 to 0.08) 0.08 ( 0.18 to 0.02) 0.735 0.109
suture right (mm)
Pterygomaxillary 0.61 6 0.14 0.59 6 0.15 0.52 6 0.09 0.02 ( 0.08 to 0.04) 0.08 ( 0.16 to 0.01) 0.424 0.035*
suture left (mm)
Nasomaxillary suture 0.68 6 0.19 0.76 6 0.19 0.59 6 0.09 0.08 (0.00-0.16) 0.08 ( 0.16 to 0.01) 0.039* 0.065
right (mm)
Nasomaxillary suture 0.69 6 0.21 0.78 6 0.24 0.60 6 0.12 0.09 (0.00-0.18) 0.08 ( 0.18 to 0.02) 0.046* 0.096
left (mm)
Zygomaticotemporal 0.63 6 0.16 0.58 6 0.20 0.59 6 0.11 0.06 ( 0.16 to 0.05) 0.06 ( 0.15 to 0.04) 0.267 0.219
suture right (mm)
Zygomaticotemporal 0.59 6 0.18 0.60 6 0.21 0.62 6 0.11 0.01 ( 0.08 to 0.11) 0.01 ( 0.09 to 0.11) 0.756 0.832
suture left (mm)
Midpalatal suture 0.48 6 0.32 1.23 6 1.03 0.49 6 0.22 0.75 (0.27-1.24) 0.02 ( 0.14 to 0.11) 0.004* 0.790
incisor (mm)
Midpalatal suture 0.57 6 0.25 1.19 6 0.89 0.51 6 0.14 0.63 (0.20-1.05) 0.06 ( 0.15 to 0.04) 0.006* 0.250
canine (mm)
Midpalatal suture 0.73 6 0.13 1.19 6 0.59 0.66 6 0.15 0.45 (0.15-0.75) 0.07 ( 0.16 to 0.02) 0.005* 0.105
molar (mm)
Note. Values are mean 6 standard deviation or mean (95% CI).
RPE, rapid palatal expansion.
*Statistically significant at P \0.05.

forces to the maxilla when activated; thus, the stresses
generated after MARPE may be similar to RPE, leading
to an increase in the width of the frontonasal suture after
expansion. Finite element analysis has been successfully
applied to identify the biomechanical components such
as displacements, strains, and stresses in living struc-
tures.31,32 A finite element analysis model has shown
that the greatest stress was concentrated at the fronto-
maxillary, nasomaxillary, and frontonasal sutures imme-
diately after the expansion force was applied.30 Thus, the
increase in the width of these sutures at T2 in the RPE
and MARPE can be attributed to the high stresses gener-
ated at these regions after expansion. However, at T3,
there was no significant difference in the width of these
sutures among MARPE, RPE, and controls.
The pterygomaxillary suture showed no significant
increase in the MARPE and RPE groups at T2 (Tables I
and II). These findings highlight the high interdigitation
of pterygomaxillary suture, contributing to the increased
resistance to palatal expansion. Pterygomaxillary suture
interdigitation increases with age.33 Previous studies
have shown that the pterygomaxillary suture is less
interdigitated at 6-7 years old, whereas dry human skulls
at 12 years old have shown heavy interdigitation of the
pterygomaxillary suture.33,34 The RPE and the control
group showed a decrease in the width of the pterygo-
maxillary suture on the left side at T3 compared with
T1 (Tables II and III). However, no difference was found
in the width of the pterygomaxillary suture in the
MARPE group

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Table III. Parameters (width of the sutures) for the control group at T1, T2, and T3
P value P value
Parameters T1 T2 T3 T2 T1 T3 T1 (T2 vs T1) (T3 vs T1)
Frontonasal suture right 0.74 6 0.18 0.75 6 0.21 0.62 6 0.33 0.01 ( 0.10 to 0.12) 0.12 ( 0.26 to 0.02) 0.828 0.093
(mm)
Frontonasal suture left 0.73 6 0.17 0.76 6 0.20 0.57 6 0.31 0.03 ( 0.07 to 0.12) 0.15 ( 0.29 to 0.01) 0.550 0.033*
(mm)
Frontomaxillary suture 0.67 6 0.16 0.59 6 0.22 0.55 6 0.22 0.07 ( 0.17 to 0.03) 0.11 ( 0.22 to 0.00) 0.154 0.053
right (mm)
Frontomaxillary suture left 0.72 6 0.22 0.67 6 0.13 0.64 6 0.21 0.06 ( 0.15 to 0.04) 0.07 ( 0.19 to 0.05) 0.250 0.244
(mm)
Zygomaticomaxillary 0.56 6 0.44 0.59 6 0.40 0.65 6 0.33 0.03 ( 0.08 to 0.14) 0.09 ( 0.06 to 0.25) 0.602 0.210
suture right (mm)
Zygomaticomaxillary 0.58 6 0.44 0.59 6 0.27 0.64 6 0.25 0.01 ( 0.14 to 0.16) 0.07 ( 0.11 to 0.24) 0.875 0.436
suture left (mm)
Zygomaticofrontal suture 0.89 6 0.27 0.81 6 0.31 0.71 6 0.26 0.08 ( 0.25 to 0.08) 0.17 ( 0.31 to 0.03) 0.306 0.023*
right (mm)
Zygomaticofrontal suture 0.89 6 0.24 0.84 6 0.33 0.67 6 0.26 0.04 ( 0.21 to 0.12) 0.21 ( 0.34 to 0.08) 0.572 0.004*
left (mm)
Intermaxillary suture (mm) 0.69 6 0.10 0.58 6 0.19 0.58 6 0.21 0.12 ( 0.22 to 0.01) 0.12 ( 0.23 to 0.00) 0.030* 0.045
Pterygomaxillary suture 0.62 6 0.17 0.63 6 0.19 0.55 6 0.15 0.01 ( 0.10 to 0.12) 0.06 ( 0.15 to 0.04) 0.828 0.225
right (mm)
Pterygomaxillary suture 0.65 6 0.18 0.58 6 0.12 0.54 6 0.13 0.06 ( 0.15 to 0.02) 0.09 ( 0.19 to 0.00) 0.111 0.049*
left (mm)
Nasomaxillary suture right 0.65 6 0.21 0.68 6 0.20 0.59 6 0.24 0.03 ( 0.12 to 0.17) 0.06 ( 0.20 to 0.08) 0.688 0.391
(mm)
Nasomaxillary suture left 0.67 6 0.23 0.70 6 0.19 0.59 6 0.22 0.03 ( 0.11 to 0.18) 0.07 ( 0.20 to 0.07) 0.640 0.306
(mm)
Zygomaticotemporal 0.57 6 0.21 0.48 6 0.21 0.59 6 0.16 0.08 ( 0.23 to 0.06) 0.03 ( 0.08 to 0.15) 0.232 0.567
suture right (mm)
Zygomaticotemporal 0.56 6 0.21 0.49 6 0.25 0.58 6 0.13 0.07 ( 0.21 to 0.07) 0.03 ( 0.08 to 0.14) 0.324 0.542
suture left (mm)
Midpalatal suture incisor 0.53 6 0.30 0.51 6 0.38 0.48 6 0.28 0.02 ( 0.17 to 0.13) 0.05 ( 0.16 to 0.06) 0.777 0.331
(mm)
Midpalatal suture canine 0.58 6 0.36 0.53 6 0.37 0.56 6 0.28 0.05 ( 0.21 to 0.10) 0.01 ( 0.15 to 0.13) 0.475 0.870
(mm)
Midpalatal suture molar 0.73 6 0.27 0.70 6 0.26 0.75 6 0.17 0.03 ( 0.12 to 0.07) 0.03 ( 0.08 to 0.14) 0.550 0.559
(mm)
Note. Values are mean 6 standard deviation or mean (95% CI).
*Statistically significant at P \0.05.

The zygomaticomaxillary, zygomaticofrontal, and
zygomaticotemporal sutures showed no significant
change in the MARPE and RPE groups (Tables I and
II). In the control group, there was a decrease in the
width of the zygomaticofrontal suture in the long term
at T3 compared with T1 (P \0.05; Table III). These find-
ings illustrate the increased interdigitation and rigidity
of these sutures. Zygomaticomaxillary, zygomaticofron-
tal, and zygomaticotemporal sutures are rightly consid-
ered to be the primary areas of resistance to maxillary
expansion.35,36 Higher rigidity of the facial skeleton
has been shown to be responsible for the failure of con-
ventional RPE.35,36 The difference in the effect of expan-
sion on the width of certain sutures and no significant
effect on other sutures in the long term demonstrates
that some sutures are affected differently than others.
This is an important factor affecting the orthopedic ef-
fect achieved with maxillary expansion.
In the short term, the midpalatal suture width at
incisor, canine, and molar levels increased significantly
after both MARPE and RPE procedures (P \0.05;
Table V). When a rapid palatal expander is activated, it
leads to horizontally directed forces on the 2 lateral
halves of the maxilla leading to the opening of the mid-
palatal suture. It has been observed that bone formation
occurs at the borders of midpalatal sutures after maxil-
lary expansion procedures.19 When observed in the
long term, it was found that the midpalatal suture width
at incisor, canine, and molar levels was significantly
higher in the MARPE group compared with RPE and
control groups (P \0.05; Table VI). Therefore, it can
be inferred that the short-term changes produced by

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Table IV. Comparison of the parameters among MARPE, RPE, and control groups at T1
P value

Parameters MARPE RPE Control Overall MARPE-RPE MARPE-control RPE-control

Frontonasal suture right 0.70 (0.58-0.82) 0.74 (0.66-0.82) 0.74 (0.65-0.82) 0.768 0.777 0.838 0.995
(mm)
Frontonasal suture left 0.70 (0.58-0.82) 0.73 (0.63-0.82) 0.72 (0.64-0.80) 0.907 0.904 0.949 0.993
(mm)
Frontomaxillary suture 0.60 (0.50-0.70) 0.62 (0.55-0.69) 0.66 (0.58-0.73) 0.583 0.900 0.556 0.810
right (mm)
Frontomaxillary suture left 0.59 (0.50-0.67) 0.66 (0.59-0.73) 0.71 (0.61-0.81) 0.118 0.438 0.100 0.642
(mm)
Zygomaticomaxillary 0.63 (0.55-0.71) 0.54 (0.39-0.70) 0.55 (0.35-0.76) 0.661 0.679 0.748 0.995
suture right (mm)
Zygomaticomaxillary 0.69 (0.58-0.79) 0.50 (0.34-0.67) 0.57 (0.37-0.78) 0.255 0.229 0.579 0.806
suture left (mm)
Zygomaticofrontal suture 0.78 (0.68-0.88) 0.80 (0.70-0.89) 0.87 (0.74-1.01) 0.407 0.976 0.422 0.537
right (mm)
Zygomaticofrontal suture 0.83 (0.74-0.92) 0.81 (0.73-0.90) 0.87 (0.76-0.99) 0.643 0.967 0.784 0.632
left (mm)
Intermaxillary suture (mm) 0.61 (0.50-0.72) 0.63 (0.47-0.79) 0.67 (0.61-0.74) 0.738 0.955 0.721 0.874
Pterygomaxillary suture 0.65 (0.59-0.71) 0.62 (0.53-0.70) 0.61 (0.53-0.70) 0.709 0.777 0.732 0.996
right (mm)
Pterygomaxillary suture 0.61 (0.55-0.66) 0.61 (0.55-0.67) 0.63 (0.54-0.73) 0.824 0.995 0.829 0.873
left (mm)
Nasomaxillary suture right 0.60 (0.46-0.73) 0.68 (0.59-0.76) 0.65 (0.55-0.75) 0.537 0.515 0.756 0.925
(mm)
Nasomaxillary suture left 0.61 (0.48-0.74) 0.69 (0.59-0.78) 0.66 (0.56-0.77) 0.602 0.589 0.771 0.957
(mm)
Zygomaticotemporal 0.55 (0.50-0.59) 0.63 (0.56-0.71) 0.56 (0.46-0.66) 0.171 0.191 0.966 0.305
suture right (mm)
Zygomaticotemporal 0.53 (0.48-0.57) 0.59 (0.50-0.67) 0.55 (0.44-0.65) 0.512 0.488 0.911 0.755
suture left (mm)
Midpalatal suture incisor 0.54 (0.45-0.63) 0.48 (0.33-0.62) 0.53 (0.39-0.68) 0.722 0.738 0.995 0.800
(mm)
Midpalatal suture canine 0.56 (0.48-0.63) 0.57 (0.45-0.68) 0.57 (0.40-0.75) 0.980 0.992 0.978 0.996
(mm)
Midpalatal suture molar 0.62 (0.53-0.71) 0.73 (0.68-0.79) 0.72 (0.59-0.85) 0.163 0.175 0.302 0.959
(mm)
Note. Values are mean (95% CI).
MARPE, miniscrew-assisted rapid palatal expansion; RPE, rapid palatal expansion.

the RPE appliance on the midpalatal suture were not
sustained in the long term.
Sutures are considered to be important sites for the
growth of bones through the period of craniofacial
development.37 Increased width of the sutures is consid-
ered an anabolic change in response to mechanical
forces leading to angiogenesis and bone apposition.38
CBCT allows reliable and accurate measurements of cra-
nial and circummaxillary sutures.24,39 A recent system-
atic review on the effect of maxillary expansion and
midpalatal sutures suggested that more high-quality
studies are needed to identify the effect of palatal
expansion on sutures using 3D radiographical methods
such as CBCT.40 In this study, it was observed that
MARPE led to a significant increase in the width of the
midpalatal suture compared with RPE and controls in
the long term. In the long term, there were no other dif-
ferences in the width of the cranial and circummaxillary
sutures among the 3 groups.
This study had some limitations, such as the accuracy
of the measurements being limited by the voxel size of
the CBCT, a retrospective study design, and a lack of a
true control group, as delayed orthodontic treatment
was rendered in the control group after T2. However,
it will not be justified ethically to record 3 CBCT scans
at 3 different time points without any treatment. The
voxel size of the CBCT impacts the accuracy of the
CBCT measurements.41 CBCT scans with smaller voxel
sizes have been shown to be more accurate, leading to
higher effective radiation doses.42 It has been shown

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Table V. Comparison of the parameters among MARPE, RPE, and control groups at T2
P values

Parameters MARPE RPE Control Overall MARPE-RPE MARPE-Control RPE-Control

Frontonasal suture right 1.00 (0.74-1.26) 0.82 (0.73-0.92) 0.75 (0.64-0.86) 0.091 0.261 0.087 0.791
(mm)
Frontonasal suture left 0.82 (0.72-0.92) 0.81 (0.72-0.91) 0.76 (0.66-0.85) 0.591 1.000 0.642 0.643
(mm)
Frontomaxillary suture 0.69 (0.60-0.79) 0.71 (0.65-0.77) 0.59 (0.48-0.70) 0.120 0.965 0.226 0.132
right (mm)
Frontomaxillary suture left 0.67 (0.58-0.77) 0.73 (0.67-0.80) 0.67 (0.60-0.73) 0.340 0.455 0.990 0.386
(mm)
Zygomaticomaxillary 0.71 (0.61-0.81) 0.63 (0.46-0.79) 0.59 (0.39-0.79) 0.527 0.718 0.512 0.927
suture right (mm)
Zygomaticomaxillary 0.78 (0.66-0.90) 0.64 (0.50-0.78) 0.59 (0.46-0.73) 0.124 0.286 0.123 0.854
suture left (mm)
Zygomaticofrontal suture 0.85 (0.76-0.94) 0.70 (0.59-0.82) 0.81 (0.65-0.96) 0.193 0.185 0.870 0.433
right (mm)
Zygomaticofrontal suture 0.85 (0.76-0.93) 0.74 (0.64-0.85) 0.84 (0.68-1.01) 0.324 0.387 0.999 0.417
left (mm)
Intermaxillary suture (mm) 0.89 (0.82-0.96) 1.02 (0.73-1.31) 0.56 (0.48-0.64) 0.003* 0.576 0.045* 0.003*
Pterygomaxillary suture 0.61 (0.51-0.71) 0.60 (0.54-0.66) 0.63 (0.54-0.73) 0.799 0.960 0.919 0.782
right (mm)
Pterygomaxillary suture 0.62 (0.53-0.72) 0.59 (0.52-0.65) 0.61 (0.53-0.70) 0.801 0.797 0.983 0.892
left (mm)
Nasomaxillary suture right 0.73 (0.65-0.80) 0.78 (0.68-0.87) 0.68 (0.58-0.78) 0.290 0.694 0.726 0.259
(mm)
Nasomaxillary suture left 0.75 (0.65-0.85) 0.79 (0.67-0.90) 0.70 (0.60-0.80) 0.475 0.843 0.786 0.441
(mm)
Zygomaticotemporal 0.60 (0.53-0.67) 0.58 (0.49-0.67) 0.48 (0.38-0.59) 0.153 0.917 0.158 0.288
suture right (mm)
Zygomaticotemporal 0.61 (0.51-0.70) 0.60 (0.51-0.69) 0.49 (0.37-0.62) 0.224 0.997 0.276 0.293
suture left (mm)
Midpalatal suture incisor 1.09 (0.80-1.38) 1.23 (0.76-1.70) 0.51 (0.33-0.69) 0.008* 0.821 0.047* 0.009*
(mm)
Midpalatal suture canine 1.09 (0.77-1.41) 1.22 (0.82-1.62) 0.54 (0.36-0.72) 0.008* 0.821 0.045* 0.008*
(mm)
Midpalatal suture molar 1.13 (0.94-1.31) 1.19 (0.92-1.46) 0.70 (0.57-0.83) 0.003* 0.907 0.014* 0.004*
(mm)
Note. Values are mean (95% CI).
MARPE, miniscrew-assisted rapid palatal expansion; RPE, rapid palatal expansion.
*Statistically significant at P \0.05.

that CBCT with a voxel size of 0.2 and 0.3 mm can be
used with reasonable accuracy compared with physical
measurements.43,44 Further studies with a longitudinal
follow-up are needed to understand the effects of the
different expansion appliances on the cranial and cir-
cummaxillary sutures.
CONCLUSIONS
1. In the short term, within the MARPE and RPE
groups, a significant increase was observed in the
width of frontonasal, frontomaxillary, intermaxil-
lary, nasomaxillary, and midpalatal sutures at
incisor, canine, and molar levels at T2 when
compared with T1.
2. In the short term, between-group comparisons
showed that MARPE and RPE led to a significant in-
crease in the width of intermaxillary and midpalatal
sutures at incisor, canine, and molar compared with
controls at T2.
3. In the long term, within the MARPE group, the
width of intermaxillary and midpalatal sutures at
the incisor, canine, and molar was significantly
increased at T3 compared with T1. Within the RPE
and control groups, the width of the pterygomaxil-
lary suture on the left side decreased significantly at
T3 compared with T1. In addition, the width of zy-
gomaticofrontal and frontonasal sutures was
decreased in the control group.

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Ahmida et al e11

Table VI. Comparison of the parameters among MARPE, RPE, and control groups at T3
P values

Parameters MARPE RPE Control Overall MARPE-RPE MARPE-control RPE-control

Frontonasal suture right 0.68 (0.54-0.83) 0.66 (0.59-0.73) 0.62 (0.46-0.77) 0.733 0.972 0.722 0.864
(mm)
Frontonasal suture left 0.67 (0.53-0.81) 0.61 (0.54-0.69) 0.57 (0.42-0.72) 0.479 0.792 0.447 0.870
(mm)
Frontomaxillary suture 0.53 (0.39-0.67) 0.53 (0.48-0.58) 0.55 (0.44-0.65) 0.965 0.998 0.979 0.966
right (mm)
Frontomaxillary suture left 0.56 (0.41-0.70) 0.59 (0.50-0.67) 0.64 (0.54-0.74) 0.513 0.907 0.488 0.761
(mm)
Zygomaticomaxillary 0.71 (0.59-0.82) 0.66 (0.56-0.77) 0.65 (0.49-0.81) 0.801 0.875 0.800 0.987
suture right (mm)
Zygomaticomaxillary 0.79 (0.71-0.87) 0.63 (0.52-0.74) 0.64 (0.52-0.76) 0.051 0.063 0.099 0.983
suture left (mm)
Zygomaticofrontal suture 0.82 (0.73-0.90) 0.73 (0.65-0.81) 0.71 (0.58-0.83) 0.238 0.424 0.234 0.918
right (mm)
Zygomaticofrontal suture 0.83 (0.74-0.92) 0.76 (0.68-0.85) 0.67 (0.54-0.79) 0.063 0.566 0.051 0.348
left (mm)
Intermaxillary suture (mm) 0.76 (0.66-0.86) 0.71 (0.40-1.02) 0.58 (0.47-0.68) 0.332 0.922 0.323 0.552
Pterygomaxillary suture 0.58 (0.52-0.64) 0.55 (0.49-0.60) 0.55 (0.48-0.63) 0.750 0.756 0.825 0.991
right (mm)
Pterygomaxillary suture 0.57 (0.52-0.63) 0.52 (0.48-0.56) 0.54 (0.47-0.60) 0.355 0.330 0.628 0.871
left (mm)
Nasomaxillary suture right 0.66 (0.57-0.75) 0.59 (0.55-0.64) 0.59 (0.47-0.71) 0.411 0.504 0.451 0.996
(mm)
Nasomaxillary suture left 0.67 (0.60-0.73) 0.60 (0.54-0.66) 0.59 (0.49-0.70) 0.343 0.439 0.384 0.995
(mm)
Zygomaticotemporal 0.59 (0.54-0.65) 0.59 (0.54-0.64) 0.59 (0.51-0.67) 0.991 0.993 0.993 .0.999
suture right (mm)
Zygomaticotemporal 0.59 (0.51-0.67) 0.62 (0.56-0.67) 0.58 (0.52-0.64) 0.695 0.822 0.974 0.687
suture left (mm)
Midpalatal suture incisor 0.69 (0.58-0.79) 0.49 (0.39-0.60) 0.48 (0.34-0.61) 0.017* 0.042* 0.026* 0.977
(mm)
Midpalatal suture canine 0.71 (0.65-0.76) 0.51 (0.44-0.58) 0.55 (0.41-0.68) 0.009* 0.011* 0.041* 0.836
(mm)
Midpalatal suture molar 1.00 (0.90-1.10) 0.66 (0.59-0.74) 0.75 (0.67-0.83) \0.001* \0.001* \0.001* 0.318
(mm)
Note. Values are mean (95% CI).
MARPE, miniscrew-assisted rapid palatal expansion; RPE, rapid palatal expansion.
*Statistically significant at P \0.05.

4. In the long term, between-group comparisons
showed no significant difference among the 3 groups
except that MARPE led to a significant increase in the
width of midpalatal suture at incisor, canine, and
molar levels compared with RPE and controls.
AUTHOR CREDIT STATEMENT
Ahmad Ahmida contributed to investigation, method-
ology, and manuscript review and editing; Shivam Mehta
contributed to supervision, conceptualization, validation,
methodology, and manuscript review and editing; Edward
Amelemah contributed to manuscript review and editing;
Rehana Bashir contributed to manuscript review and edit-
ing and formal analysis; Manuel Lagrav
ere Vich
contributed to supervision, conceptualization, and manu-
script review and editing; Aditya Tadinada contributed to
supervision, conceptualization, methodology, and manu-
script review and editing; Veerasathpurush Allareddy
contributed to supervision, conceptualization, and manu-
script review and editing; Sumit Yadav contributed to su-
pervision, conceptualization, methodology, formal
analysis, and manuscript review and editing.
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