Journal of the World Federation of Orthodontists 12 (2023) 150–155

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Journal of the World Federation of Orthodontists

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Research Article

The effects of miniscrew-assisted rapid palatal expansion on the

upper airway of adults with midpalatal suture in the last two
degrees of ossification
Fábio Ferreira Anéris a, Ossam El Haje b, Henrique Damian Rosário c, Carolina Carmo de
Menezes d, Cristina Maria Franzini d, William Custodio d,∗
a
Graduate student, Department of Orthodontics, University Center of Hermínio Ometto Foundation-FHO, Araras, Sao Paulo, Brazil
b
Professor, Departament of Oral Biology, Univeristy Center UNIFACVEST, Lages, Santa Catarina, Brazil
c
Professor, Departament of Dentistry, Universidade do Sul de Santa Catarina, Tubarão, Santa Catarina, Brazil
d
Associate Professor, Department of Orthodontics, University Center of Hermínio Ometto Foundation-FHO, Araras, Sao Paulo, Brazil

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

Article history: Background: Transverse deficiencies of the maxillary basal bone have been treated in adult patients using
Received 9 December 2022 miniscrew-assisted rapid palatal expansion (MARPE) therapy. However, the midpalatal suture’s degree of
Revised 18 May 2023
ossification may affect the upper airway dimensions. This study compared the volumetric changes of the
Accepted 18 May 2023
total upper, retropalatal, retroglossal airways, and the minimal transverse airway constriction after MARPE
Available online 20 June 2023
therapy in patients with midpalatal suture in the last stages of ossification. Methods:This controlled clin-
Keywords: ical trial included a total of 20 adult patients (mean age 24.5 ± 6.2 years) with maxillary atresia treated
Cone-beam computed tomography with MARPE. Preoperative (T0 ) cone-beam computed tomography scans were used to determine the de-
Orthodontics gree of midpalatal suture ossification. Two groups were formed considering the last two stages of sutural
Palatal expansion technique ossification “D” or “E” (n = 10 per group). After 120 days of the therapy (T1 ), cone-beam computed to-
mography assessments were performed to compare the pre and post-treatment outcomes. The total upper,
retropalatal, and retroglossal airways and the minimal transverse airway constriction were evaluated. The
three-dimensional reconstruction was performed with OsiriX MD software. The comparisons were carried
out using mixed models for repeated measures at fixed time points (α = 0.05). Results: Groups D and
E showed no significant difference for any of the analyzed parameters (P > 0.05). Both groups showed a
statistically significant increase for all airway segments after the treatment with MARPE (P < 0.05). The
total upper airway increased (11.6% and 16.1%) for groups D and E, respectively (P = 0.3356). Conclusions:
MARPE therapy resulted in dimensional gains of the upper airway for adult patients, irrespective of the
intermaxillary sutural degree of ossification.
© 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.

1. Introduction
Rapid maxillary expansion (RME) is an orthodontic procedure
commonly used for correcting transverse maxillary atresia, and one
of its aims is to improve nasal breathing [1–3]. Conventional RME
Funding: The authors have not declared a specific grant for this research from
any funding agency in the public, commercial, or not-for-profit sectors.
Competing interests: Authors have completed and submitted the ICMJE Form for
Disclosure of potential conflicts of interest. None declared.
Provenance and peer review: Non commissioned and externally peer reviewed
∗
Corresponding author: Department of Orthodontics, University Center of the
Hermínio Ometto Foundation - FHO, Av. Dr Maximiliano Baruto, 500, Araras, Sao
Paulo, Brazil.
E-mail address: williamcustodio@fho.edu.br (W. Custodio).
is indicated for children and adolescent patients in whom the in-
termaxillary suture has not completely ossified. However, in adults,
this type of therapy is normally not used for expansion because of
the level of ossification of the midpalatal suture (MS) [2].
Recently, a classification system was reported based on the level
of suture ossification characterized by five stages [4]. The lowest
level of maturation is classified as “A,” increasing progressively un-
til complete suture ossification, which is classified as stage “E [4].”
Interestingly, the degree of suture ossification was used to deter-
mine the use of surgically assisted RME. It is a clinically more in-
vasive procedure to achieve transverse correction. In this context,
miniscrew-assisted rapid palatal expansion (MARPE) therapy was
developed to correct maxillary atresia in adults without perform-
ing osteotomies and by solely exerting force directly on the basal
bones [3,5–7].

2212-4438/$ – see front matter © 2023 World Federation of Orthodontists. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ejwf.2023.05.005
 F.F. Anéris et al / Journal of the World Federation of Orthodontists 12 (2023) 150–155
The impact of RME on the upper airway of children and adoles-
cents is well established; moreover, it shows a direct and positive
correlation with the increase in maxillary width [8]. The role of
MARPE in the volumetric changes of adults’ airway spaces has been
reported without considering the various levels of MS maturation.
To date, recent studies have pointed out that MARPE significantly
increases the airway volume and the minimal cross-sectional area
of young patients [9–11]. Furthermore, in many of these studies,
the MARPE effects on airways are compared immediately after the
transverse correction, without considering a later follow-up control
assessment.
Thus, the purpose of this study was to assess, using cone-beam
computed tomography (CBCT), the effect of the stage of MS ossifi-
cation on the volumetric changes of an adult patient’s postmaxil-
lary expansion with MARPE.
2. Methods and materials
This double-blind, prospective clinical trial was submitted to the
Ethics and Scientific Merit Committee and approved under the pro-
tocol CAAE: 03245518.3.0 0 0 0.5385 and registered by the Brazilian
Registry of Clinical Trials (project code: RBR-4pgktym).
Patients in the initial stage of orthodontic treatment were se-
lected in accordance with the following eligibility criteria: age 18
years or older, presence of maxillary atresia, and healthy maxil-
lary first premolars and first molars. Exclusion criteria for the study
were subjects with respiratory diseases diagnosed by otolaryngolo-
gists or speech-language pathologists, pathologies or morphologic
Fig. 1. Consort flow diagram for sample allocation.
151
anomalies that affected the craniofacial or head and neck struc-
tures, previous craniofacial or head and neck surgeries, fixed or re-
movable oral appliances, and previous orthodontic treatment. The
flow diagram of sample composition is presented in Fig. 1.
Pretreatment CBCT images (T0 ) were used to evaluate the stages
of maturation of the MS in accordance with Angelieri et al. (2013)
[4], as previously described. The patients presenting fusion com-
pleted in the palatine bone with no evidence of a suture were clas-
sified in the D ossification stage, forming the “D” group. Individuals
presenting fusion anteriorly in the maxilla were classified as stage
E, forming the “E” group. A total of 20 adults, with an average age
of 24.5 ± 6.2 years and a man-to-woman ratio of 1:5, were catego-
rized into two groups based on their MS maturational level: group
E (n = 10) and group D (n = 10) (Fig. 1). A power analysis indi-
cated that the sample size provided a test power of 80%, with a
level of significance of 5%. All statistical analyses were carried out
using the G∗ Power software (G∗ Power Team, Düsseldorf, Germany)
[12].
All participants received numerical codes to promote blinding
during both the intervention phase and the CBCT analysis of the
experimental variables. The order of patient allocation for imple-
menting the therapy was randomized by a simple draw of the
codes previously applied.
2.1. Intervention
The MARPE therapy was carried out for patients in both groups,
following a standardized protocol [13,14]. Briefly, after the molars
152 F.F. Anéris et al / Journal of the World Federation of Orthodontists 12 (2023) 150–155
were banded, the transfer impressions were taken with Hydrogum
alginate (Zhermack, Badia Polesine, RO, Italy). The plaster models
(Durone type IV, Dentsply Sirona, York, PA) were sent to the labo-
ratory for fabrication of the MARPE type appliances with expander
screws (PecLab Belo Horizonte, MG, Brazil). Before inserting the
mini-implants, the cortical bone was manually preperforated with
a burr 1.1 mm in diameter and a contra-angle screwdriver (PecLab,
Belo Horizonte, Brazil). The appliance was cemented with Meron
glass ionomer (Voco, Cuxhaven, Germany) for immediate insertion
of four mini-implants (PecLab, Belo Horizonte, MG, Brazil) with a
contra-angle reducer (20:1) and surgical electric motor (NSK, Shi-
nagawa, Tokyo, Japan) with a standardized torque of 30 N. Based
on the initial tomograph (T0 ), the length and diameter of the mini-
implants were chosen for each patient, taking into account the
palate bone thickness in the area of the maxillary first molars. The
mini-implant insertion was concluded with a manual ratchet key
(Neodent, Curitiba, Brazil).
Evaluations were made until overcorrection of the transverse
problem was obtained (the palatine cusp of maxillary molars al-
most on top of the vestibular cusp of mandibular molars) to avoid
a certain degree of relapse [14,15]. After the conclusion of the
activations, the expander screw was locked [16,17]. After 120 days,
a new CBCT was taken to evaluate the opening of the MS (T1 ).
Fig. 2. Cross-sectional CBCT images showing the anatomical limits of the different segments of the airway space: total upper airway (A), retropalatal airway (B), retroglossal
airway (C), and minimal transverse constriction (D).
2.2. Volumetric evaluation of the upper airway by CBCT
CBCT images were obtained (at T0 and T1 ) using an iCAT Vision
scanner (Imaging Science International, Hatfield, PA). The scanning
parameters were 120 kV, 36.12 mAs, an exposure time of 40 sec-
onds, a field of view of 130 mm, and a voxel size of 0.25 mm.
The position of the head was oriented so that the Frankfort plane
would be parallel to the ground in the seated position, and the im-
ages were obtained in the intercuspal position [2]. The CBCT data
were reconstructed in the Digital Imaging and Communications in
Medicine (DICOM) file format.
The position of the head was reoriented for each scan so that
in a frontal view, a skeletal midline (nasion and anterior nasal
spine) would be demarcated, and this would be perpendicular to
the ground so that the plane from this point on would terminate
perpendicular to the palatine plane in the axial and sagittal seg-
ments [18]. The volumetric evaluation of the airways in the pre
and post-MARPE images were made by the same researcher, using
OsiriX MD software (Version 9.5.2, 64-bit) (Geneva, Switzerland)
[19].
Based on this marking, the software created a lateral cephalo-
metric image at the midsagittal plane [18]. From this view, the up-
per airway segments were demarcated in accordance with a proto-
 F.F. Anéris et al / Journal of the World Federation of Orthodontists 12 (2023) 150–155 153

Table 1
Intraexaminer comparisons of the CBCT three-dimensional and linear measurements of upper airway segments.

Parameters First measurement Second measurement ࢞ first–second Dahlberg error ICC (CI 95%) P-value
Mean (SD) Mean (SD) Mean (SD)

Total upper airway (cm3 ) 15.78 (6.04) 15.82 (6.09) 0.04 (0.14) 0.099 1.000 (0.999-1.000) 0.0728
Retropalatal airway (cm3 ) 8.34 (2.58) 8.36 (2.64) 0.02 (0.21) 0.147 0.998 (0.997-0.999) 0.4794
Retroglossal airway (cm3 ) 7.46 (4.05) 7.48 (4.04) 0.02 (0.18) 0.124 1.000 (0.999-1.000) 0.5253
Minimal transverse constriction (cm2 ) 1.74 (0.77) 1.74 (0.77) 0.00 (0.00) 0.000 1.000 (1.000-1.000) 1.0000

CBCT, cone-beam computed tomography; CI 95%,: 95% confidence interval; ICC, intraclass correlation coefficient.

Table 2
Comparisons between tomographic measurements of the different upper airway portions, considering intermaxillary suture degree of ossification (stage) and time of obser-
vation (general linear model).

Parameters Stage Time point

Pretreatment (T0 ) Post-treatment (T1 )

Mean (SD) Mean (SD)

Total upper airway (cm3 ) D 16.18 (5.58) Ba 18.06 (5.52) Aa

E 13.41 (5.99) Ba 15.57 (7.05) Aa
P (stage) = 0.3356; P (time) = 0.0050; P (interaction) = 0.8128
Retropalatal airway (cm3 ) D 8.34 (2.60) Ba 9.05 (2.53) Aa
E 7.69 (2.76) Ba 8.31 (2.77) Aa
P (stage) = 0.5502; P (time) = 0.0437; P (interaction) = 0.8879
Retroglossal airway (cm3 ) D 7.85 (3.51) Ba 9.01 (3.57) Aa
E 5.75 (3.83) Ba 7.26 (4.99) Aa
P (stage) = 0.2868; P (time) = 0.0044; P (interaction) = 0.6719
Minimal transverse constriction (cm2 ) D 1.71 (0.64) Ba 2.08 (0.62) Aa
E 1.41 (0.80) Ba 1.75 (0.94) Aa
P (stage) = 0.3614; P (time) < 0.0001; P (interaction) = 0.8024

Different letters (capitals comparing the horizontal and lower case letters comparing the vertical) indicate statistically significant differences (P ≤ 0.05).

col described previously by Chang et al. [18]. The following param-
eters were assessed: airway volumes for the total upper (Fig. 2A),
retropalatal (Fig. 2B), and retroglossal airways (Fig. 2C). In addition,
minimal transverse airway constriction was obtained (Fig. 2D).
Briefly, the complete upper airway was limited upward by a
plane connecting the posterior nasal spine to the basion and down-
ward by another horizontal plane crossing through the most supe-
rior point of the epiglottis; both planes were parallel to the Frank-
furt horizontal plane. The upper airway was divided into an upper
segment (retropalatal airway) and an inferior segment (retroglos-
sal airway) after establishing a third horizontal plane crossing the
most posteroinferior point of the soft palate, traced parallel to pre-
viously described planes [18]. Once the segments were delimited,
the three-dimensional reconstruction was carried out (Fig. 3A and
B), and the volumetric measurements of the upper airway seg-
ments and the area of the minimum transverse constriction were
calculated automatically by the software [19]. All CBCT measure-
ments were carried out in duplicate, and the arithmetic mean was
calculated.
2.3. Statistical analysis
The interexaminer reliability was evaluated by Dahlberg error,
intraclass correlation analysis, and paired t test after all the mea-
surements of the complete sample were reprocessed by the same
operator within a 2-week interval [20]. For comparisons between
the groups and time intervals, a mixed model for repeated mea-
sures at fixed time points was used. The analyses were performed
with the R software environment for statistical computing [21]. The
level of significance was set at P ≤ 0.05.
3. Results
An interpretation of the intraclass correlation coefficient
demonstrated that the means were excellent (intraclass correlation
coefficient ≥ 0.75) [22]. No significant difference could be observed
between the two measurements (P > 0.05). The Dahlberg error
ranged from 0.099 to 0.147 cm3 , i.e., from 0.6% to 1.8% in relation
to the mean value of the measurements (Table 1).
The comparisons between groups D and E at T0 and T1 revealed
no statistically significant differences (P > 0.05) for the total upper,
retropalatal, and retroglossal airways or the minimal transverse air-
way constriction (Table 2 and Fig. 3). The statistical analysis of the
results showed statistically significant increases for all volumetric
parameters and minimal transverse airway constriction (P < 0.05)
between the pre- and postperiods, irrespective of the sutural mat-
uration level (Table 2).

4. Discussion

A successful expansion of the maxillary suture seems not to af-

fect the upper airway’s aerodynamic characteristics [23]. However,
in the present study, it was demonstrated that MARPE therapy sig-
Fig. 3. Three-dimensional reconstruction of the total upper airways of the individ- nificantly improved the volumetric parameters in the upper air-
uals’ representative of groups “D” and “E” (A and B, respectively). way spaces, irrespective of the level of MS ossification. Consider-
154 F.F. Anéris et al / Journal of the World Federation of Orthodontists 12 (2023) 150–155
ing both groups D and E, the upper airway volume presented an
average increase of about 14%. This therapeutic effect corroborated
the findings of a previous study that observed an increase in na-
sopharyngeal volume of approximately 8.48% [24]. Therefore, this
suggests that MARPE can produce transverse bone expansion with
secondary effects on the upper airways. This result demonstrated
a similarity of the secondary response of MARPE to the effects re-
sulting from conventional RME in children and surgically assisted
RME in adults [1,25,26].
From the three-dimensional analysis, it was possible to observe
that the different segments of the upper airways increased in vol-
ume after 4 months of locking the expander screw, irrespective of
the level of suture ossification. It is important to note that the oral
airway has a rigid roof, the hard palate, and thus, a direct rela-
tionship between the distance of the hemimaxillae and the trans-
verse gain of the floor of the nose, close to the MS and nasal cav-
ity, can be established, in addition to the distancing of the lateral
walls of the nasal cavity [27,28]. Whereas the pharyngeal airways
(composed of the nasopharynx, retropalatal oropharynx, retroglos-
sal oropharynx, and hypopharynx) do not have rigid supporting
structures and are maintained by the muscles, structures around
them, and posture [29].
The transverse maxillary expansion associated with posterior
crossbite correction using MARPE therapy may have resulted in the
anterior displacement of the mandible, resulting in an increase of
the pharyngeal airway space [30]. Furthermore, a more anterior lo-
calization of the tensor veli palatini muscle, which is responsible
for the tension of the palatine aponeurosis of the soft palate, could
be related to an increase in the oropharyngeal airway in individuals
with maxillary atresia after maxillary expansion [31]. Furthermore,
it is important to note that MARPE probably directly increased the
volume of the nasal cavity and indirectly increased the volume of
the pharynx. However, more controlled studies must be conducted
to confirm these assumptions [32].
There was no statistically significant change in the upper airway
structures after MARPE therapy in the function of the MS degree of
ossification (P > 0.05). This result was unexpected because it ap-
peared contradictory that the group with less ossification should
have the same volumetric gain as the group with the completely
fused suture. This finding could have resulted from a pattern of MS
opening that was not completely parallel, as also observed in the
studies of RME expansion [33,34]. Further studies are necessary to
elucidate the association between the pattern of MS opening in pa-
tients with different levels of suture ossification.
Previous studies have demonstrated that to obtain good skeletal
results using MARPE, the force used must be sufficiently strong to
overcome the areas of resistance of the sutures. In this context, it is
important to highlight that the intermaxillary suture interdigitation
continues to increase after the period of adolescence [13,14,35]. It
is also important to point out that in the present study, the op-
tion was to perform CBCT (T1) 120 days after the active treat-
ment to avoid transitory effects such as mandibular rotation in
the clockwise direction or edema that could generate unreliable
results [18].
Clinically, the present study allowed the clarification that no ev-
idence supports the hypothesis that the MS degree of ossification
hampers the volumetric gain of the upper airway spaces. The vol-
ume gain of retropalatal space in those patients was significantly
smaller than the other portions, irrespective of the sutural ossifi-
cation level. It may also be because of the pterygomaxillary joint
complex, whose morphology has a wide range of variation between
individuals and affects the opening of the MS [36]. Therefore, fu-
ture research is needed to determine whether MARPE affects the
specific parts of the pharynx differently.
5. Conclusion
The volumetric characteristics of the upper airway are signifi-
cantly increased after MARPE, irrespective of the stage of MS ossi-
fication.
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