Article

Title

Skeletal and Dento-alveolar Effects Using Different Types of Microimplant-assisted Rapid Palatal
Expansion (MARPE)

Hyeong-Yoon Choi, Sang-Min Lee*, Jin-Woo Lee, Dong-Hwa Chung, Mo-Hyeon Lee

Department of Orthodontics, College of Dentistry, Dankook University, Cheonan 330714, Korea;

ltl8787@naver.com (H.-Y.C.); jwlee1945@hanmail.com (J.-W.L.); abeh@dankook.ac.kr (D.-H.C.);
dignityoflmh@naver.com (M.-H. L.)

* Correspondence: leesm0624@dankook.ac.kr

Abstract:

Objective: To evaluate the following null hypothesis: there is no difference in the coronal and axial
expansion patterns in skeletal and dentoalveolar measurements using two different types of
microimplant-assisted rapid palatal expansion (MARPE) Methods: Pretreatment (T0) and post-
MARPE (T1) cone-beam computed tomography (CBCT) images of 32 patients (14 men and 18
women; mean age, 19.37) were analyzed. We compared two different types of MARPEs. The first
type of MARPEs include maxillary first premolars, maxillary first molars, and four microimplants as
anchors (U46 type, n=16) and the other include only maxillary first molars and microimplants as
anchors (U6 type, n=16). Results: In the molar region of the U6 type, the amount of midnasal, basal,
alveolar, and dental level transverse expansion was 2.64 mm, 3.52 mm, 4.46 mm, and 6.32 mm,
respectively. whereas in the U46 type, 2.17 mm, 2.56 mm, 2.73 mm, and 5.71 mm were acquired,
respectively. A significant difference was found in the posterior alveolar level expansion (P_alv), (p
= 0.036) and posterior basal bone level expansion (P_basal), (p=0.043) between groups, showing a
greater posterior skeletal and alveolar expansion in the U6 type. Conclusions: The U6 type showed
a greater amount of posterior expansion at the alveolar and basal bone level, showing an almost
parallel split compared with the U46 type. Both types of MARPE showed a pyramidal pattern of
expansion in coronal view.

*Keywords: microimplant-assisted rapid palatal expansion; maxillary transverse discrepancy; cone-

beam computed tomography; bicortical engagement
1. Introduction

Rapid palatal expansion (RPE) is a treatment of modality in patients with transverse discrepancy,
which is reported to prevalence varying from 8% to 23%. It is reported to be approximately 10%
in adults,1 and Proffit et al. 2 reported that 30% of adults had a transverse discrepancy. RPE
enables maxillary skeletal expansion by separating midpalatal suture treating bilateral or unilateral
buccal crossbite. RPE is indicated in mixed dentition until adolescence for growing patients.3 For
young adults and adolescents after growth spurt who present skeletal maturity, however, the
nonsurgical RPE can cause well-known side effects, including buccal tipping of anchored teeth,
loss of buccal alveolar bone height, detrimental periodontal consequences, and lack of long-term
stability.4-7 The skeletal expansion of RPE is obtained through overcoming resistance from
zygomatic buttress and separation of circum-maxillary sutures, such as midpalatal suture and
pterygopalatine suture7,8 which are difficult to disarticulate due to increase of bone density and
interdigitation with aging. Therefore, in adults, surgically assisted rapid palatal expansion (SARPE)
or with various uses of temporary anchorage device (TAD) in dentistry, microimplant-assisted rapid
palatal expansion (MARPE) is recommended in case of maxillary constriction.4,9 Although, SARPE
can resolve the constriction of the maxilla surgically, there are problems of cost, time, and burden
due to a surgery. Also, according to a recent study, a more parallel expansion pattern at the palate
and basal bone was presented in the MARPE group compared with the SARPE group in coronal
and axial planes.4

Figure 1. MARPE appliance A, U46 type, Microimplant-assited rapid palatal expansion (MARPE), (MSE-12;
Biomaterials, Seoul, Korea) B, U6 type, Microimplant-assited rapid palatal expansion (MARPE), (MSE-12;
Biomaterials, Seoul, Korea).

MARPE utilizes four palatal microimplants combined with a palatal expander and each type uses
maxillary first premolars and molars or just first molars for the anchors of the appliance. These two
types of MARPE use different microimplant sites derived from positioning of jackscrew (anterior and
posterior), (Figure 1). The U6 type include posterior jackscrew and microimplants, while the U46
type include anterior jackscrew and microimplants between maxillary first premolars and first
molars.1 Despite several studies on coronal and axial expansion effects of MARPEs, there is a lack
of data comparing two different types of MARPE in a study amongst orthodontists.1,10-13
 Cone-beam computed tomography (CBCT) allows imaging at relatively low radiation dosages and
shows the skeletal and dentoalveolar structure with minimal image distortion.14-17 Unlike two-
dimensional (2D) radiographs, CBCT enables distinguishing angular and linear movement of each
tooth and three-dimensional (3D) changes in the maxillofacial complex after maxillary expansion.18
In a previous study, Lim et al. 19 reported stability of skeletal, alveolar, and dental changes of the
hybrid hyrax expander (which is similar to the U46 type in this study) using CBCT, and de Oliveira
et al. 4,20 compared the skeletal and dentoalveolar changes of MSE (maxillary skeletal expander),
(which is similar to the U6 type in this study) using CBCT.

The present study aimed to evaluate different expansion amount and pattern of two different
types of MARPE in axial (anterior, posterior) and coronal plane (skeletal, alveolar, and dental) and
compare the differences between the two types (U6 type and U46 type) at pre- and post-expansion
CBCT images. Our null hypothesis is that there is no difference in the coronal and axial expansion
patterns in skeletal and dentoalveolar measurements using two different types of MARPE (U6 type
and U46 type).

2. Materials and Methods

2.1. Subject

This clinical study was previously approved by the Institutional Review Board of Dankook
University Dental Hospital (DKUDH IRB 2021-9-003).

In this retrospective study, the samples consisted of 36 patients treated using MARPE, diagnosed
with the transverse discrepancy, since April 2005 in the Department of Orthodontics, College of
Dentistry in Dankook University, South Korea. Patients qualifying inclusion criteria were recruited
consecutively, and out of 36 patients, four failed to exhibit opening of the midpalatal suture. finally,
this study included 32 patients (14 men and 18 women), showing 88.9% of the maxillary expansion
success rate, with a mean age of 19.37 (minimum, 12; maximum, 29).
Figure 2. Re-orientation A, Sagittal view, palatal plane parallel to the axial plane B, 3D image, lower margin of
orbit parallel to the axial plane in coronal view C, D, Axial view, passing through both palatal root canal of the
maxillary first premolars (C) and first molars (D).

All subjects were selected to qualify the following inclusion criteria: 1) Age greater than 12 years
2) Patients taking serial CBCT images before maxillary expansion (T0) and after 3-month retention
periods of maxillary expansion (T1) 3) Having no general diseases or congenital cranial
malformations 4) Patients showing midpalatal suture split after maxillary expansion on post-MARPE
CBCT images (T1) 5) Having no impacted tooth of maxillary first premolars and maxillary first molars
6) Having no history of previous orthodontic treatment.

2.2. Treatment protocol

In this study, we compared two different types of tooth and bone-borne MARPEs. The first type
of MARPEs include maxillary first premolars, maxillary first molars and four microimplants as anchors
(U46 type, n=16), and the other type includes only the maxillary first molars and microimplants as
anchors (U6 type, n=16), (Figure 1). Before using MARPE, palatal bone depth was measured by initial
CBCT images (T0) after re-orientation (Figure 2) for bicortification of palatal and nasal floor cortical
bone.21 Based on measured depth, the length of microimplants was selected. The MARPE (MSE-12,
type I; 0.8mm expansion in 4 turns (1 revolution); Biomaterials, Seoul, South Korea) device was made
passive contact with the underlying tissue and soldered to four bands in the U46 type and two
bands in the U6 type. Following the cementation of the device to the maxillary first premolars and
molars (U46 type) and the maxillary first molars (U6 type), four titanium microimplants (OAS-T1511;
1.5 mm x 11 mm / OSA-T1513; 1.5 mm x 13 mm, Biomaterials, Seoul, Korea) were installed in the
slots of the device.22

The microimplants were installed symmetrically based on the midpalatal suture with a contra-
angle engine driver for positioning. After that, the MSE ratchet wrench driver was used to install
the rest of the screw and the insertion torque was measured between 15N and 20N. Activation
protocol was 2 turns/day until reaching prescribed expansion amount.23 The amount of expansion
was determined based on the Yonsei Transverse Index (YTI), the distance difference between the
furcation of the maxillary first molar and the mandibular first molar, and patients were checked once
every 1 or 2 weeks until YTI reaches normal range (YTI in normal occlusion; -0.39 ± 1.87 mm).24

2.3. Measurements

CBCT images were acquired in C-mode (full skull mode) for 17 seconds, with a voxel size of 0.39
mm, using a CT scanner (Alphard VEGA; ASAHI Roentgen IND, Kyoto, Japan) set at 6.0 mA and 80
kV. Patients were asked to sit upright, with the Frankfort horizontal plane parallel to the floor. The
images were imported as DICOM files using 3D imaging software InVivo5® (Anatomage, San Jose,
CA, USA), and all measurements were made. Image re-orientation was done with the lower margin
of orbit parallel to the axial plane in coronal view and a palatal plane parallel to the axial plane in
sagittal view, as shown in Figure 2.

To evaluate the maxillary expansion at the alveolar level, we used measurements from a previous
study of Magnusson A et al.25 Ectocanine, which is the most infero-lateral point on the alveolar
ridge at the center of the maxillary canine; Ectopremolare, the most infero-lateral point on the
alveolar ridge at the center of the maxillary first premolars; Ectomolare, the most lateral and inferior
point on the alveolar ridge at the center of the maxillary first molar on both sides were measured
(Figure 3).
Figure 3. Landmarks used in this study, 1; the most lateral point of nasofrontal suture, 2; the most lateral point
of the nasal cavity, 3; the most infero-lateral point of zygomaticomaxillary suture, 4; Ectocanine, the most
infero-lateral point on the alveolar ridge at the center of the maxillary canine, 5; Ectopremolare, the most
infero-lateral point on the alveolar ridge at the center of the maxillary first premolar, 6; Ectomolare, the most
infero-lateral point on the alveolar ridge at the center of the maxillary first molar. Definition of measurements
is shown in Table1.

For measurement of skeletal expansion, bilateral nasofrontal suture width (BNSW), nasal cavity
width (NCW), and zygomaticomaxillary suture distance (ZD) were measured on a 3D coordinate
system of reconstruction images. On the coronal plane slice, after re-orientation of the 3D images,
two coronal scans were obtained passing through the palatal root canal of the maxillary first
premolars and molars. The distance between the most medial points of the basal bone was
measured for the basal bone level premolar width (BL_PMW) and basal bone level molar width
(BL_MW). The distance between the most lateral point of the nasal cavity was measured for the
midnasal level premolar width (MNL_PMW) and midnasal level molar width (MNL_MW), (Figure 4).
Figure 4. Skeletal expansion measurement A, The distance between the most lateral point of the nasal cavity
was measured for the mid nasal level premolar width (MNL_PMW) and the most medial points of the basal
bone at the junction of the lateral wall of the maxillary sinus and the buccal cortical bone of the maxillary
alveolar bone were measured for the basal bone level premolar width (BL_PMW) B, The distance between the
most lateral point of the nasal cavity was measured for the mid nasal level molar width (MNL_MW), and the
most medial points of the basal bone at the junction of the lateral wall of the maxillary sinus and the buccal
cortical bone of the maxillary alveolar bone were measured for the basal bone level molar width (BL_MW).

Figure 5. Dental linear measurement, Interpremolar width (IPW), and intermolar width (IMW) were measured
for the dental linear measurement on a 3D coordinate system.
Figure 6. Dental angular measurement A, Angle between the fossa-palatal root apex lines of the maxillary first
premolars was measured for inter-premolar angle (IPA) B, Angle between the fossa-palatal root apex lines of
the maxillary first molars was measured for inter-molar angle (IMA)

Inter-premolar width (IPW) and intermolar width (IMW) were measured for the dental linear
measurement on a 3D coordinate system, which, respectively, mean the distances between the
buccal cusp tips of the maxillary first premolars and mesiobuccal cusp tips of the maxillary first
molars (Figure 5). For the dental angular measurement, the angle between the fossa-palatal root
apex lines of the maxillary first premolars was measured for inter-premolar angle (IPA), and the
angle between the fossa-palatal root apex lines was measured for inter-molar angle (IMA), (Figure
6). The landmarks and measurements evaluated in this study and their definitions are summarized
in Table1, 2 and Figure 3.

Table 1. Definition of skeletal and dental measurements

Measurement Measurement
Description
(abbreviation) dimension
Skeletal measurement
Bilateral nasofrontal Distance between the most lateral point of the
3D coordinate system
suture width (BNSW) nasofrontal suture point
Distance between the most lateral point of the nasal
Nasal cavity width (NCW) 3D coordinate system
cavity
Zygomaticomaxillary Distance between the most infero-lateral point of the
3D coordinate system
suture distance (ZD) zygomaticomaxillary suture
Distance between the most medial point of basal bone at
Basal bone level premolar
Coronal plane slice the coronal slice of the
width (BL_PMW)
premolar region
Distance between the most medial point of basal bone at
Basal bone level molar
Coronal plane slice the coronal slice of the
width (BL_MW)
molar region
Midnasal level premolar Distance between the most lateral point of the nasal
Coronal plane slice
width (MNL_PMW) cavity at the coronal slice of the premolar region
Midnasal level molar width Distance between the most lateral point of the nasal
Coronal plane slice
(MNL_MW) cavity at the coronal slice of the molar region
Alveolar measurement
Distance between the most infero-lateral alveolar ridge
Ectocanine width (ECW) 3D coordinate system
point of the maxillary canine
Ectopremolare width Distance between the most infero-lateral alveolar ridge
3D coordinate system
(EPMW) point of the maxillary first premolar
Distance between the most infero-lateral alveolar ridge
Ectomolare width (EMW) 3D coordinate system
point of the maxillary first molar
Dental measurement
Distance between the bilateral buccal cusp of maxillary
Inter-premolar width (IPW) 3D coordinate system
first molar
Distance between the bilateral mesiobuccal cusp of the
Inter-molar width (IMW) 3D coordinate system
maxillary first molar
Inter-premolar angle (IPA) Coronal plane slice Angle between the fossa-apex (palatal root) line
Inter-molar angle (IMA) Coronal plane slice Angle between the fossa-apex (palatal root) line

Table 2. Combination of measurements in Table 1

Combination of measurement
Amount of expansion Formula Description
∆BNSW (T1) – Amount of bilateral nasofrontal suture width
∆BNSW
∆BNSW (T0) expansion before and after MARPE
∆NCW (T1) – Amount of nasal cavity width expansion before
∆NCW
∆NCW (T0) and after MARPE
Amount of zygomaticomaxillary suture distance
∆ZD ∆ZD (T1) – ∆ZD (T0)
expansion before and after MARPE
Amount of anterior dental width expansion before
A_den IPW (T1) – IPW (T0)
and after MARPE
Amount of posterior dental width expansion
P_den IMW (T1) – IMW (T0)
before and after MARPE
Amount of anterior alveolar width expansion
A_alv EPMW(T1) – EPMW(T0)
before and after MARPE
Amount of posterior alveolar width expansion
P_alv EMW(T1) – EMW(T0)
before and after MARPE
BL_PMW (T1) – Amount of anterior basal width expansion before
A_basal
BL_PMW (T0) and after MARPE
BL_MW (T1) – Amount of posterior basal width expansion before
P_basal
BL_MW (T0) and after MARPE
MNL_PMW (T1) – Amount of anterior midnasal width
A_mid
MNL_PMW (T0) expansion before and after MARPE
MNL_MW (T1) – Amount of posterior midnasal width
P_mid
MNL_MW (T0) expansion before and after MARPE
Difference in anterior and posterior
AP_den P_den – A_den
dental width expansion
Difference in anterior and posterior
AP_alv P_alv – A_alv
alveolar width expansion
Difference in anterior and posterior
AP_basal P_basal – A_basal
basal width expansion
Difference in anterior and posterior
AP_mid P_mid – A_mid
midnasal width expansion
Figure 7. Bicortical engagement of the palatal and nasal floor cortical bone by microimplants A, Coronal view
B, Sagittal view.

The bicortical engagement of the palatal and nasal floor cortical bone by microimplants was
observed from the coronal and sagittal views to analyze the number of bicortically engaged
microimplants upon the type of MARPEs (Figure 7).

2.4. Statistical analysis

A minimum of 12 patients in each group were required to maintain a power of at least 80% with
a significance level of 0.05. A pilot test was conducted at the beginning of this study. The sample
size calculation was performed with G*power 3.1.9.4 for Windows (University of Duesseldorf,
Germany). All data were analyzed with the use of SPSS for Windows ver. 25.0 (SPSS Inc., Chicago,
IL, USA). All measurements were performed by a single examiner (H.Y.C.). To determine the intra-
examiner error, we selected 10 samples 2 weeks after the initial measurement and re-measured
them. All intraclass correlation coefficients (ICC) were above 0.907, indicating high reproducibility.

Normality test of the data was done using the Shapiro–Wilk test and the Levene test was used
to evaluate the homogeneity of distribution. In this study, we made a linear mixed-effects model
including age, amount of expansion, and retention period to determine variables that affect changes
between the types of MARPE (U6 type and U46 type) and found no confounding factor.

To compare the difference between the U6 type and the U46 type, independent t-test and Mann-
Whitney U test were used. Paired sample t-test and Wilcoxon signed rank test were used to compare
skeletal and dentoalveolar measurements at T0 and T1 within groups, according to the normality of
data distribution. A significance level of p < 0.05 was used.
3. Results

Table 3. Comparison of the number of populations, age, YTI value and amount of expansion

U6 type (SD) U46 type (SD) p-value

N 16 16
Age (year) 19.5 (4.27) 19.06 (4.73) 0.696
YTI value (mm) at T0 -3.45 (0.85) -2.91 (0.91) 0.101
Amount of prescribed expansion
6.66 (2.03) 5.60 (2.00) 0.148
(mm)
YTI value (mm) at T1 -0.25 (0.56) -0.49 (0.56) 0.250
Duration of retention (day) 123.81 (59.75) 164.19 (126.34) 0.261
YTI, Yonsei transverse index; SD, standard deviation; N, number of the subjects

The mean amount of prescribed expansion was 6.13 ± 2.06 mm (U6 type; 6.66 ± 2.03 mm / U46
type; 5.60 ± 2.00 mm) and duration of mean retention periods was 144.0 days (U6 type; 123.81 /
U46 type; 164.18), (Table 3). After that, second CBCT images (T1) were taken.

After three months of the post-expansion retention period, in the molar region of the U6 type,
the amount of midnasal, basal, alveolar, and dental level transverse expansion was 2.64 mm, 3.52
mm, 4.46 mm and 6.32 mm, respectively. In the U46 type, 2.17 mm, 2.56 mm, 2.73 mm, and 5.71
mm was acquired, respectively. A significant difference was found in the alveolar level expansion
(P_alv), (p=0.036) and basal bone level expansion (P_basal), (p=0.043) between groups, showing
more posterior skeletal and alveolar expansion in the U6 type (Table 4).

Table 4. Comparison of the amount of skeletal, alveolar, and dental maxillary expansion in each type of MARPEs

U6 type vs.
U6 type U46 type
U46 type
Mean Mean
Measurement Landmark SD p-value SD p-value Comparison p-value
difference difference

Skeletal ∆BNSW 0.47 0.83 0.039 0.67 0.91 0.01 0.525

∆NCW 2.68 1.97 <0.001 2.31 1.61 <0.001 0.724a

∆ZD 3.07 1.77 <0.001 2.68 2.16 <0.001 0.578

A_mid 2.69 1.43 <0.001 2.14 1.35 <0.001 0.184a

P_mid 2.64 1.25 <0.001 2.17 1.11 <0.001 0.239a

A_basal 2.85 1.82 <0.001 2.56 2.02 <0.001 0.402a

U6 type >
P_basal 3.53 2.01 <0.001 2.31 1.43 <0.001 0.043a*
U46 type

Alveolar A_alv 4.08 2.03 <0.001 4.29 1.69 <0.001 0.745

U6 type >
P_alv 4.46 2.23 <0.001 2.73 2.22 <0.001 0.036*
U46 type
 Dental A_den 4.77 2.22 <0.001 5.32 2.41 <0.001 0.505

P_den 6.33 2.19 <0.001 5.65 2.57 <0.001 0.428

* p < 0.05; SD, standard deviation; N, number of the subjects; a, Mann-Whitney U test

Table 5. Anterior and posterior linear difference (mm) in expansion between the U6 type and the U46 type
(posterior – anterior)

U6 type U46 type

Mean SD Mean SD p-value
AP_den (mm) 1.58 2.47 0.33 1.99 0.138
AP_alv (mm) 0.69 1.43 -1.56 2.09 0.001a***
AP_basal (mm) 0.68 0.88 -0.22 1.67 0.077
AP_mid (mm) -0.05 1.09 0.04 0.96 0.818
*** p < 0.001; SD, standard deviation; a, Mann-Whitney U test

The anterior and posterior difference in expansion between MARPE types shows a significant
difference in AP_alv (p < 0.001), in which 0.69 mm more expansion was obtained in the molar region
using the U6 type, whereas, in the U46 type, 1.56 mm less expansion was obtained in the molar
region at the alveolar level (Table 5).

In a group of the U6 type in the molar region, the alveolar level expansion was 109% compared
with the premolar region. However, in the group of the U46 type, the alveolar level expansion was
64% in the molar region compared with the premolar region. The amount of dental expansion was
not significantly different between groups (Table 4).

Both groups presented pyramidal maxillary expansion in coronal view: the more upper the
anatomical structure is located from the appliance, the less expansion was acquired. In the U6 group,
BNSW, NCW, ZD increased 0.47 mm, 2.68 mm, and 3.07 mm (p < 0.05), respectively, at T1. Whereas
in the U46 group, the increase was 0.67 mm, 2.31 mm, and 2.68 mm (p < 0.05), respectively, at T1.
None of the above measurements was significantly different between groups (Table 4).

Table 6. Anterior and posterior angular difference (°) in expansion between the U6 type and the U46 type
(posterior – anterior)

U6 type (SD) U46 type (SD) p-value

Inter-premolar angle (T1-T0) 2.64 (5.88) 6.04 (5.18) 0.036*
Inter-molar angle (T1-T0) 7.06 (5.27) 5.88 (6.49) 0.752a
T0, pretreatment; T1, after 3-month retention periods of maxillary expansion; * p < 0.05; SD, standard deviation;
a, Mann-Whitney U test

In angular measurements (T1-T0), IPA in the U6 type and the U46 type was increased by 2.64̊
and 6.04̊ (p = 0.036), respectively. IMA was increased by 7.06̊ and 5.88̊ in each group, respectively
(p = 0.752), (Table 6).

4. Discussion

We used CBCT in this study to evaluate post-expansion skeletal and dentoalveolar changes
between the U6 type MARPE and the U46 type MARPE. Especially, we are focusing on the difference
of the coronal and axial expansion in each type of MARPEs.

Most previous studies have described the orthopedic effects of RPE and MARPE.26-29 Gunyuz Toklu
et al.27 compared the skeletal effects produced by hybrid expanders (both tooth and bone supported)
with traditional tooth-supported expanders Altieri et al.29 compared tooth-borne expanders with
bone-borne expanders showing greater expansion in width of nasal floor, which is consistent with
this study. Whereas, Lagravere et al.28 compared skeletal-supported (using two anterior palatal
microimplants) expanders with tooth-supported expanders and did not find any statistically
significant differences in the skeletal structures which is not consistent with our study. Unlike
previous studies, we compared two types of tooth and bone-borne MARPE (U46 type and U6 type
both using four microimplants in different position) in both axial and coronal plane. In this study,
out of 36 patients, four patients showed no signs of midpalatal suture spit, showing 88.9% of success.
We also found significance between the number of bicortically engaged microimplants upon type
of MARPEs (Table 7).

Table 7. Number of bicortically engaged microimplants upon MARPE type

U6 type (SD) U46 type (SD) p-value

Number of bicortically
3.88 (0.5) 2.56 (0.96) 0.001***a
engaged microimplants
*** p < 0.001; SD, standard deviation; a, Mann-Whitney U test

Lione et al.20 presented a study using a conventional RPE on growing patients and reported that
the opening of the anterior and posterior midpalatal suture split was 3.01 mm (ANS) and 1.15 mm
(PNS), which means that 40% of the anterior opening was obtained at the posterior part, showing
the fan type expansion. However, Cantarella et al.7 reported, using an MSE expander, midpalatal
suture split at PNS (4.3 mm) was 90% of that at ANS (4.8 mm). Different biomechanics in MSE using
four microimplants, compared to conventional RPE, caused expansion forces closer to the maxilla's
center of resistance, therefore, obtaining more skeletal expansion of the maxillary complex.13,30,31 As
we can easily find patients with bilateral or unilateral crossbite in molar region, most patients with
transverse discrepancy need more posterior expansion than that of anterior. Recently, Lee et al.21
reported that in MARPE with four bicortically engaged microimplants, the posterior region of the
maxilla had more expansion than the anterior region, and the ratio was 111%. This series of studies
has shown that the presence of a skeletal anchorage in maxillary expansion increases posterior
expansion by better overcoming the structures that resist expansion in the posterior region,32-34
such as midpalatal suture, zygomatic buttress, and pterygopalatine suture. This study also showed
similar results; in the U6 type, alveolar expansion in the maxillary first molars and first premolars
was 4.46 mm and 4.08 mm, respectively (Table 4) and AP_alv showed a significantly greater value
meaning more posterior alveolar expansion than the U46 type (p=0.001), (Table 5). The posterior
basal bone expansion was 3.53 mm in the U6 type, showing more posterior skeletal expansion than
that of the U46 type (2.31 mm), (p=0.043), (Table 4).

In a similar age group with SARPE, parallel expansion in axial view was obtained upon the release
of pterygoid plates.35 When the pterygoid plates were not released, the amount of anterior
expansion was greater than that of the posterior.5,36,37 This means among the circum-maxillary
sutures and structure resisting maxillary expansion, the disarticulation of the pterygopalatine suture
is the most important factor for successful maxillary expansion. In this study, the number of
bicortically engaged microimplants originated from MARPE designs (U46 type, U6 type) was one of
the main factors for releasing pterygopalatine suture and obtaining maxillary expansion (Table 7).

Lee et al.21 recently reported a significant correlation between the number of microimplants with
bicortical engagement and pterygopalatine suture openings. In this study, we also observed that a
significantly greater number of microimplants were bicortically engaged in the U6 type (3.88 ± 0.5)
compared to the U46 type (2.56 ± 0.96), (Table 7) and more alveolar and skeletal expansion was
found in the U6 type.7,20 As a result, the ability of the U46 type to resist sutures in the posterior
region to promote the posterior suture split was less than that of the U6 type.

Since the palatal soft tissue thickness along the midpalatal suture become thickest at the point
4mm behind the incisive papilla,38 If the MARPEs were placed in the anterior slope of the palate,
the depth of the microimplant placed inside the bone is shallower than the MARPE placed at the
posterior region. Therefore, there is a need to use longer microimplants for bicortical engagement.
Our samples also support that the in the U46 type, the anterior microimplants rarely penetrate the
nasal floor cortical bone.
Figure 8. Comparison of the amount of skeletal, alveolar, and dental maxillary expansion in the U6 and the U46
type of MARPEs in the premolar and molar area.

The maxillary expansion shows pyramidal shape, which decreases as it vertically moves upward
from the device. Anatomically, the higher the structure, the smaller the amount of transverse
expansion. In the molar region of the U6 type, basal and alveolar expansion were greater than that
of the U46 type, implying that more skeletal expansion was obtained (Figure 8).

Factors for efficient maxillary expansion by different types of MARPE include

 Bicortical microimplant is a critical factor, causing pterygopalatine suture opening and

parallel skeletal expansion.21,31,33

 The vertical location of expansion jackscrew caused different patterns of expansion. The
deeper the palatal vault, the more direct force (close to the center of resistance of the
maxilla) can be applied to the circum-maxillary sutures and basal bone. When
microimplants were installed in the deeper palate, in the posterior region, the leverage
effect was less than conventional RPE.

 MARPEs placed in the posterior region overcome the resistance of the pterygopalatine
 suture and zygomatic buttress bone well.39 Whereas, when placed in the anterior palatal
slope, bicortical engagement is hard to achieve, and the stability is lower than the case of
bicortical engagement in which microimplants resist lateral force more effectively.33

Among the factors that affect the expansion of MARPE, the distance from the posterior
microimplant to the ANS would have an effect, in addition to the bicortical engagement. As a
further study, the post-MARPE difference in multiplane upon the distance from palatal microimplant
to ANS would be a valuable study. In this study, the average distance in the U6 and the U46 types
was 38.91 mm and 29.26 mm, respectively (Figure 9).

Figure 9. ANS-posterior microimplant distance A, distance from ANS to posterior microimplant in the U46
group (mean distance, 29.26mm) B, distance from ANS to posterior microimplant in the U6 group (mean
distance, 38.91mm)

Regarding dental tipping, the degree of buccal tipping in the maxillary first molars was higher
than that of premolars in the U6 type. Also, as expected, the angular change of the maxillary first
premolar in the U46 type was greater than that of the U6 type (Table 6). The jackscrew exerting
lateral forces caused the bending of the alveolar bone in the posterior teeth40 and tipping of the
anchored teeth.41 De Oliveira et al.4 reported an average of 3.3° of buccal inclination in the first
molar using MSE. In this study, the change of intermolar angle was 7.06̊ (U6 type) and 5.88̊ (U46
type), respectively. We observed a slight increase in dental tipping compared to previous studies
and we consider residual stress of the MARPE during the retention period as one of the possible
causes of the difference. As like other studies, the degree of buccal tipping of the maxillary first
molar was greater than that of the first premolar in the U6 type. However, a similar degree of buccal
tipping was observed in the maxillary first premolar and molar in the U46 type.

Based on these results, It is possible to know the ratio of skeletal, alveolar, and dental expansion.
Also clinicians can be able to clearly recognize the difference in the anterior-posterior dental and
skeletal effects at various vertical levels, upon design of the MARPE and utilize the appliance suitable
for each indication.

As a limitation of the present study, additional studies with long-term follow-ups and larger
samples are needed to accurately evaluate the skeletal (basal bone and midnasal level) expansion
differences between groups. Moreover, analysis about long-term stability of skeletal expansion effect
after different types of MARPE is needed to further our knowledge to help clinicians select the
appropriate expansion appliance for their patients.

5. Conclusions

The null hypothesis of this study was rejected. The findings of this study are as follows:

1. In both types, MARPE efficiently splits the sutures. The U6 type showed greater expansion at the
alveolar and basal bone level in the posterior part, showing an almost parallel split than the U46
type. Whereas in the U46 type, a more anterior midpalatal suture opening was found than the
posterior part.

2. Both types of MARPE showed a pyramidal pattern of expansion in coronal view. In the U6 type,
basal and alveolar expansion were greater than that of the U46 type, in molar region which means
more skeletal expansion was obtained.

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