ORIGINAL ARTICLE

Treatment effects after maxillary

expansion using tooth-borne vs
tissue-borne miniscrew-assisted rapid
palatal expansion appliance
Ruoyu Ning,a,b Junjie Chen,a Siling Liu,a and Yanqin Lua
Changsha, Hunan, China

Introduction: The study investigated the skeletal effects and root resorption in young adults with maxillary trans-
verse deficiency after tissue-borne or tooth-borne mini-implant anchorage maxillary expansion. Methods:
Ninety-one young adults with maxillary transverse deficiency, aged 16-25 years, were divided into 3 groups ac-
cording to the treatment method: group A (n 5 29) comprising patients treated with tissue-borne miniscrew-
assisted rapid palatal expansion (MARPE), the group B (n 5 32) comprising patients treated with tooth-borne
MARPE, and the control group (n 5 30) comprising patients only treated with fixed orthodontic therapies.
Pretreatment and posttreatment cone-beam computed tomography images were used to assess the change
of maxillary width, nasal width, first molar torque and root volume by paired t test in the 3 groups,
respectively. Analysis of variance and Tukey least significant difference analysis were used to detect the
changes of all descriptions among the 3 groups P \0.05. Results: In the 2 experimental groups, we observed
significant increases in the width of the maxilla, nasal, and arch width, as well as the molar torque. In addition, the
height of the alveolar bone and the root volume decreased significantly. There were no significant differences in
the maxilla, nasal, and arch width change between the 2 groups. Group B displayed more increases in buccal
tipping, alveolar bone loss, and root volume loss than group A (P \0.05). Compared with groups A and B, the
control group showed negligible tooth volume loss, with no expansion effect in both skeletal and dental descrip-
tions. Conclusions: Tissue-borne MARPE produced the same expansion efficiency as tooth-borne MARPE.
However, tooth-borne MARPE causes more dentoalveolar side effects in buccal tipping, root resorption and
alveolar bone loss. (Am J Orthod Dentofacial Orthop 2023;-:---)

M
axillary transverse deficiency (MTD) is a kind of
common malocclusion in all ages, which af-
fects maxillofacial development and functions
with varying degrees. It has been reported to affect
8.0%-23.3% of patients in primary and mixed dentition1
and 9.4% in adults.2 The main clinical manifestation is a
transverse maxillary deficiency, including but not limited
a
Department of Orthodontics, Xiangya Stomatological Hospital and Xiangya
School of Stomatology, Hunan Clinical Research Center of Oral Major Diseases
and Oral Health, Central South University, Changsha, Hunan, China.
b disorder, and nasal stenosis.4
Third Xiangya Hospital and Xiangya School of Medicine, Central South Univer-
sity, Changsha, Hunan, China.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Yanqin Lu, Department of Orthodontics, Xiangya
Stomatological Hospital and Xiangya School of Stomatology, Hunan Clinical
Research Center of Oral Major Diseases and Oral Health, Central South University,
No. 72 Xiangya Rd, Changsha 410000, Hunan, China; e-mail, 213031@csu.edu.
cn.
Submitted, October 2022; revised and accepted, February 2023.
0889-5406/$36.00
Ó 2023.
https://doi.org/10.1016/j.ajodo.2023.02.022
to dentition crowding, mandible deviation, procum-
bency, widened buccal vestibular sulcus, and unilateral
or bilateral posterior crossbite, which cannot be self-
corrected.3 If the correct treatment and intervention
are not performed in time, the condition may gradually
worsen and progress into an uncoordinated vertical and
sagittal maxillofacial skeleton along with complications,
such as periodontal tissue damage, mandibular func-
tional displacement, temporomandibular joint or muscle
Rapid maxillary expansion (RME) is the most com-
mon and reliable treatment method to correct transverse
maxillary deficiencies for prepubertal and adolescent pa-
tients, including conventional RME, surgically-assisted
rapid palatal expansion (SARPE) and miniscrew-
assisted rapid palatal expansion (MARPE). However,
conventional RME uses natural teeth as anchorage to
transmit mechanical expansion forces, sometimes pro-
ducing limited skeletal effects because of the

Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
2 Ning et al
interdigitation of the midpalatal suture and adjacent ar-
ticulations in adults and young adults.5 Such conditions
may produce unwanted consequences, such as root
resorption, alveolar bone bending, fenestration, frac-
ture, periodontal damage, dental buccal tipping, palatal
cusp ptosis, alveolar bone loss, gingival recession, and
mandibular clockwise rotation.6-8 SARPE is designed
for older patients by releasing the closed sutures
resisting expansion force. However, SARPE has higher
financial costs, larger surgical trauma and
unpredictable surgical complications, which make most
patients difficult to accept the procedures.9 As such,
scholars at home and abroad focus their research on
MARPE, which has been designed to correct a transverse
maxillary deficiency in adults, and it can directly force on
screws, significantly increasing the orthopedic expan-
sion efficiency and reducing biological and financial
costs, producing fewer dentoalveolar side effects
mentioned earlier when compared with conventional
RME and SARPE.10
There are variable designs and implantation sites for
MARPE, in which the most well-known device is the
maxillary skeletal expansion. The efficacy and complica-
tions of different MARPE designs are controversial.11
Miniscrew-assisted devices do not mean a complete
absence of dental side effects during maxillary expan-
sion. It was reported that MARPE would still lead to
root volume loss and dental tipping of the anchorage
teeth.12 To guide the choice of the clinical treatment
plan, this study used the cone-beam computed tomog-
raphy (CBCT) to detect the maxillary width, nasal width,
first molar torque, and root volume in young adults with
MTD before and after using different MARPE appliances.
MATERIAL AND METHODS
All experimental protocols in this study were
approved by the Medical Ethics Committee of Xiangya
Stomatological Hospital. Written informed consent was
obtained from all participants.
This retrospective study selected young adults aged
16-25 years with MTD as the experimental subjects.
The research was performed on the basis of the measure-
ments from 42 males and 49 females who accepted
tissue-borne MARPE, tooth-borne MARPE or only fixed
orthodontic treatment between October 2021 and June
2022 at the Xiangya Stomatological Hospital of Central
South University. Subjects were selected according to the
following principles: (1) MTD with tissue-borne MARPE,
tooth-borne MARPE or only fixed orthodontic treat-
ment; (2) no growth potential, skeletal age: cervical
vertebrae maturational stages 5-6; (3) qualified CBCT
data before and after MARPE; (4) no orthodontic
- 2023  Vol -  Issue -
Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
treatment history; (5) no craniofacial anomalies,
syndromes, severe asymmetries, or clefts; and (6) no
other systemic disease or clinical history.
The control group included patients who rejected
maxillary expansion and only received fixed orthodontic
treatment without tooth extraction. In the 2 experi-
mental groups, patients were treated with a modified
tissue-borne or a tooth-borne MARPE appliance.
Ninety-two subjects with maxillary expansion were
selected initially, but 9 subjects maintained their appli-
ance in the mouth \6 months after the expansion pro-
cess. Ten subjects had an insufficient activation of
jackscrew, and 12 patients had either a screw depth
that was too deep or too shallow. Sixty-one subjects
finished the expansion process, achieved clinical success,
fulfilled the inclusion criteria, and were enrolled in the
study (Fig 1).
Tooth-borne MARPE appliance is fixed to the palatal
bone with screws and covers the lateral side teeth with
metal stents, whereas the tissue-borne MARPE appliance
is fixed to the palatal bone with only screws (Fig 2).
Before manufacturing this appliance, Neoanchor Plus
(KJ Meditech, Seoul, South Korea) miniscrews of 1.6-
10.0 mm were applied perpendicular to the hard palate
and 6-10 mm beyond the palatal gingival margin. The
MARPE appliance was stabilized and kept as retention
for about 6 months after the expansion process to main-
tain the effect of maxillary expansion, and no direct
force was applied to the teeth during this period. CBCT
images were obtained when the appliance was
removed.13
Data including CBCT images before and after maxil-
lary expansion therapies of the subjects in experimental
groups were accessed with the teeth in centric occlusion
at the end of swallowing (New Tom 5G CBCT scanner;
QR system, Verona, Italy) with exposure settings of
110 kVp, 12-inch field of view, and 5.4-second exposure
time), which made an exact diagnosis and acquire the in-
formation of tooth volume and skeletal conditions (all of
the CBCT images were calibrated and obtained by the
same observer).
Head positions were standardized in CBCT according
to the horizontal and sagittal planes. The horizontal
plane was positioned passing through the superior
border of the external acoustic meatus and the inferior
border of the infraorbital margin of both sides. The
sagittal plane was positioned passing through the ante-
rior nasal spine, the internasal suture and the glabella.
Measurement of maxillary width, nasal width and first
molar torque were designated on the 2-dimensional
(2D) surface in the Dolphin Imaging software (version
11.8; Dolphin Imaging and Management Solutions,
Chatsworth, Calif; Fig 3 and Table I).
American Journal of Orthodontics and Dentofacial Orthopedics
Ning et al
Fig 1. Study flow chart. MARPE, miniscrew-assisted rapid palatal expansion.
Fig 2. Two kinds of MARPE appliance design. MARPE,
miniscrew-assisted rapid palatal expansion.
Measurement of root volume was carried out in
Mimics software (version 21; Materialise, Leuven,
American Journal of Orthodontics and Dentofacial Orthopedics
Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
3
Belgium). For better analysis and understanding of the
changes in volume, the root was further divided into 8
parts: the palatal root of U6, the mesial buccal root of
U6, the distal buccal root of U6, the root of U5, U4,
U3, U2, and U1. Three-dimensional reconstruction of
the target teeth was performed with Mimics software us-
ing the crop mask, region grow, split mask, and edit
mask commands, by setting 3 orthogonal sections
(sagittal, coronal, and cross-sections). The root segmen-
tation was performed with the multiple slice edit com-
mand in the Mimics software according to the
cementoenamel junction. The volume was acquired in
the command properties by executing the calculate
part command.14 The percentage of tooth loss was
calculated from the following formula: % tooth loss 5
(pretreatment root volume posttreatment root
volume)/pretreatment root volume 3 100%.
A double-blind protocol was performed (ie, patient
treatment was performed by 1 clinician for all subjects,
whereas the assessments after treatment were done by
another evaluator blinded to the treatment protocol
and the history of each subject).15
Statistical analysis
All data were analyzed using SPSS (version 21; IBM,
Armonk, NY). Kolmogorov-Smirnov and Fanchazzi ana-
lyses were used for the homogeneity of variance test and
normal distribution, and statistical significance was es-
tablished at a 5 0.05. A paired t test was used to detect
the change in maxillary width, nasal width, first molar
- 2023  Vol -  Issue -
4 Ning et al

Fig 3. Definition of measurements (from left to right): (1) Nasal width, maxillary width, and arch width;
(2) Tooth inclination: the angle between the palatal root axis of molars and the HP; (3) Alveolar bone
loss: measured from the alveolar crest on the buccal side to the HP.

Table I. Detailed definitions of each measurement

Measurements Definitions
NN Nasal width between the most lateral wall of the nasal cavity
NF Maxillary width tangent to the nasal floor at its most inferior level
HP Maxillary width parallel to the lower border of the CBCT images and tangent to the hard palate
MWA Intermolar width between the palatal apices of the first molars
MWC Intermolar width between the palatal cusps of the first molars
Tor-R The angle between the palatal root axis of the right molar and NF
Tor-L The angle between the palatal root axis of the left molar and NF
AH-R Alveolar bone loss: distance between the alveolar crest on the buccal side to the NF of the right molar
AH-L Alveolar bone loss: distance between the alveolar crest on the buccal side to the NF of the left molar
U6P Palatal root volume of U6
U6DB Distal buccal root volume of U6
U6MB Mesial buccal root volume of U6
U5 Root volume of U5
U4 Root volume of U4
U3 Root volume of U3
U2 Root volume of U2
U1 Root volume of U1
Percentage of tooth loss (Pretreatment root volume posttreatment root volume)/pretreatment root volume 3100%
HP/MWC The ratio of skeletal/dental expansion: change of maxillary width (HP)/change of intermolar width (MWC) 3 100%

torque, and root volume between pretreatment and
posttreatment in the 3 groups, respectively. Analysis of
variance and Tukey least significant difference tests
were used to detect the changes in all descriptions
among the 3 groups P \0.05. To assess the reliability
of these measurements, all quantifications were digi-
tized and duplicated twice by the investigator (R.N),
with a 1-week time interval. An intraclass correlation co-
efficient (ICC) was used to determine the intraobserver
reliability of the measurements through reliability anal-
ysis in SPSS. Reliability was divided into 3 categories:
poor (ICC \0.40), fair to good (0.40 # ICC # 0.75),
and excellent (ICC .0.75).16
RESULTS
Kolmogorov-Smirnov and Fanchazzi tests (P .0.05)
showed that each dataset conforms to the homogeneity
of variance test and normal distribution. The
retrospective power was from 0.824 to 0.901, calculated
using PASS software (NCSS LLC, Kaysville, UT). The in-
traobserver reliability of the measurements of all de-
scriptions using SPSS software was good to excellent,
with ICCs ranging from 0.686 (fair to good) to 0.923
(excellent).
There was no significant difference in the amount of
activation of the MARPE jackscrew and the depth of
screws between the 2 experimental groups (Table II). In
addition, a significant difference in gender, age, and
the interval of taking CBCT was not observed among
the 3 groups. CBCT images on midpalatal sutures and
the depth of screws of a typical patient after tooth-
borne MARPE were shown in Figure 4.
Compared with pretreatment data, groups A and B
showed significant increases in the width of the maxilla
(NF, HP), nasal cavity (NN), and arch width (MWA,
MWC), with the unexcepted results that 2 types of the

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

Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
Ning et al 5

Table II. The distribution of the gender, age, and interval of taking CBCT of the patients in the 3 groups
Variables Group A, n 5 29 Group B, n 5 32 Control group, n 5 30 P value
Gender NS
Female 16 17 16
Male 13 15 14
Age, y NS
Range 16.5-25.1 16.3-25.7 16.1-25.4
Mean 6 standard deviation 20.8 6 3.0 20.1 6 3.2 20.2 6 3.0
Time, mo NS
Range 6.2-7.5 6.0-7.2 6.5-7.8
Mean 6 standard deviation 6.8 6 0.5 6.6 6 0.6 7.1 6 0.4
Depth of screws, mm NS
Range 3.5-5.6 3.2-5.8 –
Mean 6 standard deviation 4.3 6 0.6 4.4 6 0.8 –
Activation of jackscrew, mm NS
Range 4.2-5.0 4.3-5.0 –
Mean 6 standard deviation 4.6 6 0.3 4.7 6 0.2 –

NS, not significant.

Fig 4. CBCT images on midpalatal suture and the depth of miniscrew of a typical patient after tooth-
borne MARPE. CBCT, cone-beam computed tomography; MARPE, miniscrew-assisted rapid palatal
expansion.

devices significantly affected the molar torque and the
height of alveolar bone after MARPE (Table III). In addi-
tion, the root volume loss (U6P, U6MB, U6DB, U5, U4,
P \0.05) of the 2 groups indicated an undesired tooth
side effect during the expansion period. No significant
differences between pretreatment and posttreatment
data were detected in the control group.
There were no significant differences in the amount
of maxillary width (NF, HP), nasal cavity (NN), and
arch width (MWA, MWC) between the 2 experimental
groups (Table IV). All of the increments were signifi-
cantly larger than that of the control group. In the 2
experimental groups, the amount of expansion
decreased from NF to MWC. Group B displayed more
torque and buccal tipping increases and more alveolar
bone loss at the first molars than group A and the control
group. The loss of tooth root volume in the U4, U5, and
U6 was apparent in the 2 experimental groups, and the
loss of tooth root volume in the U3 was only detected
in group B. In addition, group B showed more volume

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

Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
6 Ning et al

Table III. Root volume and dentoskeletal descriptions changes for the 3 groups
Group A (n 5 29) Group B (n 5 32) Control group (n 5 30)

Measurements Pretreatment Posttreatment P value Pretreatment Posttreatment P value Pretreatment Posttreatment P value
NN 32.4 6 2.5 36.1 6 3.0 \0.001 32.0 6 2.2 36.8 6 3.9 \0.001 33.1 6 2.7 33.5 6 2.2 0.564
NF 67.7 6 5.3 72.2 6 6.5 \0.001 67.5 6 5.5 73.5 6 7.0 \0.001 66.8 6 6.0 66.9 6 5.3 0.725
HP 65.8 6 4.8 70.8 6 5.1 \0.001 66.1 6 4.7 71.2 6 5.4 \0.001 66.0 6 5.1 65.8 6 5.5 0.490
MWA 35.5 6 2.4 41.2 6 3.3 \0.001 34.2 6 2.1 41.0 6 3.5 \0.001 35.3 6 2.6 36.0 6 3.0 0.562
MWC 45.8 6 4.0 53.0 6 4.8 \0.001 46.0 6 3.8 52.4 6 4.4 \0.001 45.1 6 4.2 45.2 6 4.1 0.871
Tor-R 102.6 6 7.1 106.2 6 7.3 0.002 101.8 6 7.9 107.3 6 8.6 \0.001 100.5 6 7.7 101.2 6 8.9 0.435
Tor-L 101.4 6 6.9 105.4 6 8.8 0.001 102.4 6 7.0 108.4 6 8.9 \0.001 103.0 6 6.5 103.4 6 6.4 0.765
AH-R 13.9 6 1.5 12.6 6 2.1 0.002 14.3 6 1.8 11.5 6 1.9 \0.001 14.1 6 1.2 13.0 6 1.8 0.672
AH-L 12.6 6 1.7 11.8 6 1.4 0.003 12.9 6 2.3 10.3 6 1.2 \0.001 12.5 6 1.9 11.9 6 2.4 0.931
U6P 82.5 6 16.8 78.4 6 14.9 \0.001 83.2 6 17.9 77.7 6 15.5 \0.001 81.7 6 13.8 80.5 6 13.8 0.718
U6DB 70.3 6 12.3 61.6 6 10.8 \0.001 69.3 6 11.5 58.4 6 9.6 \0.001 70.5 6 11.2 68.2 6 12.0 0.694
U6MB 69.7 6 13.0 61.0 6 11.3 \0.001 71.5 6 14.3 61.8 6 9.9 \0.001 70.6 6 13.5 69.1 6 12.5 0.730
U5 165.4 6 35.8 150.2 6 32.1 0.002 164.3 6 32.7 141.4 6 27.5 \0.001 163.9 6 33.7 159.7 6 31.6 0.652
U4 140.2 6 24.6 127.5 6 21.7 0.001 141.0 6 25.8 117.5 6 20.2 \0.001 141.5 6 26.0 140.4 6 22.5 0.478
U3 229.7 6 36.1 220.0 6 11.3 0.113 221.5 6 34.3 192.5 6 19.9 0.001 224.6 6 14.5 219.1 6 22.4 0.460
U2 185.4 6 25.4 180.3 6 22.4 0.752 179.9 6 24.5 174.4 6 23.5 0.467 181.9 6 27.1 179.7 6 31.6 0.671
U1 203.2 6 29.0 200.5 6 21.5 0.891 210.0 6 27.8 207.5 6 20.2 0.582 207.5 6 26.8 205.4 6 24.8 0.450

loss in all the root volume measurements than group A
except U6P, U2 and U1. There were statistically signifi-
cant differences in the percentage of tooth loss at the
U6DB, U6MB, U5, U4, and U3 between groups A and
B, among which the value at the U6DB, group A
(13.2% 6 3.1%) and group B (17.6% 6 2.9%), were
the highest. The control group showed no expansion ef-
fect in both skeletal and dental descriptions and negli-
gible tooth volume loss compared to the 2
experimental groups.
DISCUSSION
The mechanical forces of conventional RME-
generating expansion are transmitted to the palatal su-
tures through the teeth and palatal mucosa. Some un-
desirable complications may occur during the
expansion process, such as buccal tipping, root resorp-
tion of the anchorage teeth, fenestration, fracture,
periodontal damage, and gingival recessions.17,18
MARPE has been introduced to correct MTD as a
bone-borne RME method that directly transmits
expansion forces by screws instead of natural teeth to
avoid these complications. Variable designs and im-
plantation sites for MARPE were proposed, in which
the most well-known device is the maxillary skeletal
expansion. Of other methods, some are bone-borne de-
vices with teeth anchorage, whereas others without
teeth anchorage.8,19 All of them still have dental effects
and undesirable complications. This study showed both
tissue-borne and tooth-borne devices made significant
increases in the maxilla, nasal, and arch width
compared with the control group. In addition, there
was no difference in the expansion efficiency between
these 2 experimental groups. However, the amount of
increase in molar torque, the amount of decrease in
alveolar bone height and the amount of root volume
loss in the tooth-borne group were larger than that
of the tissue-borne group with less inflammation and
edema on palatal soft tissue, which indicated MARPE
without teeth anchorage might be one of the ways to
reduce the adverse dental effects, but not a good
way to reduce soft discomfort.
Many studies have concluded that MARPE could in-
crease the nasal cavity width,20 consistent with the re-
sults of this study (NN). An increased nasal cavity may
facilitate nasal ventilation and nasal breathing of
patients with constricted airways and mouth
breathing.21,22
Better treatment effects of both appliances were
shown when compared with the control group, and
the amount of maxillary transverse expansion at the
skeletal level in experimental groups was great. More
surface contact area between expansion devices and
anchorage teeth that has been shown to be a more sig-
nificant contributor to skeletal expansion than only
mini-implants allowed for more valid force transfer. In
the experimental groups, the amount of expansion
decreased from NF to MWC, showing a pyramidal
pattern of maxillary expansion, consistent with previous
studies. MARPE often showed a more parallel expansion
pattern than conventional RME.23,24 In our study, the
geometric shape varied depending on the different
anchorage of expanders. The shape of the pyramidal

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

Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
Ning et al 7

Table IV. Analysis of variance and Tukey least significant difference analysis for volume and dentoskeletal mean
changes among the 3 groups
Changes Percentage of tooth loss

Group A Group B Control group Group A Group B Control group

Measurements (n 5 29) (n 5 32) (n 5 30) P value (n 5 29) (n 5 32) (n 5 30) P values
NN 4.5 6 0.6 5.1 6 0.9 0.7 6 0.2 0.001*
NF 4.6 6 0.9 5.2 6 1.3 0.3 6 0.1 0.001*
HP 5.3 6 0.8 5.5 6 0.8 0.2 6 0.1 0.001*
MWA 5.2 6 1.2 6.0 6 1.4 0.9 6 0.3 0.001*
MWC 6.1 6 1.1 6.9 6 0.9 0.3 6 0.1 0.001*
Tor-R 4.6 6 0.3 6.8 6 1.0 1.1 6 0.4 0.002*
Tor-L 4.7 6 0.8 6.3 6 1.2 0.8 6 0.2 0.001*
AH-R 2.0 6 0.5 4.4 6 1.1 1.2 6 0.2 0.002*
AH-L 1.1 6 0.6 3.7 6 0.9 1.1 6 0.3 0.003*
U6P 4.9 6 2.3 6.1 6 2.1 2.9 6 1.7 0.074 5.2 6 0.8 6.4 6 1.2 1.0 6 0.2 0.012*
U6DB 10.2 6 1.5 12.7 6 2.0 2.5 6 0.8 0.001* 13.2 6 3.1 17.6 6 2.9 2.4 6 0.5 0.003*
U6MB 8.1 6 1.3 10.5 6 2.5 2.6 6 1.5 \0.001* 11.5 6 1.9 14.0 6 2.0 1.9 6 0.1 0.001*
U5 15.5 6 3.7 23.8 6 4.8 3.1 6 1.6 \0.001* 10.2 6 2.0 14.2 6 2.4 2.8 6 0.8 \0.001*
U4 14.6 6 2.6 20.6 6 3.9 1.6 6 0.7 \0.001* 10.0 6 2.5 14.5 6 3.3 0.7 6 0.2 \0.001*
U3 6.3 6 2.2 27.5 6 2.8 3.9 6 1.3 0.001* 2.4 6 1.7 13.6 6 2.0 2.2 6 0.1 0.019*
U2 5.2 6 1.5 3.4 6 1.1 2.7 6 0.5 0.792 3.2 6 0.6 2.7 6 0.4 1.1 6 0.3 0.833
U1 3.8 6 0.6 2.6 6 0.5 2.1 6 0.4 0.457 1.4 6 0.3 1.5 6 0.1 0.9 6 0.1 0.756
HP/MWC 87.2 79.7 66.7 \0.001*
P values

Measurements Group A vs B Group A vs control Group B vs control Group A vs B Group A vs control Group B vs control
NN 0.538 0.001* 0.001*
NF 0.274 0.002* 0.001*
HP 0.633 0.001* \0.001*
MWA 0.575 0.003* 0.002*
MWC 0.452 0.002* 0.004*
Tor-R 0.002* 0.010* 0.008*
Tor-L 0.001* 0.007* 0.004*
AH-R 0.022* 0.265 0.032*
AH-L 0.013* 0.314 0.026*
U6P 0.074 0.004* 0.038* 0.462 0.012* \0.001*
U6DB 0.001* 0.001* 0.001* 0.036* 0.001* 0.005*
U6MB \0.001* 0.003* 0.005* 0.033* \0.001* 0.002*
U5 \0.001* 0.012* 0.013* 0.027* 0.008* 0.001*
U4 \0.001* \0.001* \0.001* 0.014* 0.016* 0.016*
U3 0.001* 0.276 0.001* 0.001* 0.857 0.004*
HP/MWC 0.654 \0.001* \0.001*

*Statistically significant (P \0.05).

pattern in group B showed more parallel expansion than
in group A.
The torque change of anchorage teeth in groups A
and B was less notable than that in a study with con-
ventional RME.20 The torque change of anchorage
teeth in the study resulted from both the dental tipping
and the inevitable alveolar tipping with the outward
rotation of the maxilla. The amount of dental tipping
in group B was 1.5 times of that in group A, which
implied that there was significant buccal tipping
when there were anchorage teeth in expansion devices.
Group B also showed greater expansion at the apex
palatal root apex of the first molar (MWA) than that
at the maxilla (NF, HP), which indicated that the
apex moved laterally in the alveolar housing. The rigid-
ity of the appliance resisting the buccal tipping of the
banded teeth may result in the lateral movement of the
apex.8
The loss of buccal vertical alveolar bone was observed
in the experimental groups. The amount of group B was
more than that of group A. We believe such reduction
was related not only to the buccal inclination of
anchorage teeth in group B but also to the overall buccal
movement of anchorage teeth, the thickness of the

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

Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
8 Ning et al
alveolar bone itself, and individual periodontal response
difference.25-27
Root resorption caused by orthodontic tooth move-
ment has been observed as root shortening in the apical
regions on 2D x-ray images. However, root morphology
changes often occur on the root lateral. It means the
3-dimensional root resorption cannot be reflected by
2D root length shortening, which may lead to unreliable
results. The CBCT, having the advantages of convenient
image processing, quickly obtained, low radiation dose,
can quantitatively measure root volume, minimize the
problems of distortion and deformation in traditional
2D image examination, and greatly improve the accu-
racy.28-30 It has already been used to measure the root
volume loss of the maxillary teeth during RME in
previous studies.31-33 In this study, the CBCT
3-dimensional reconstruction technology was used to
measure the root volume loss, and the result had good
repeatability and stability.
In patients with maxillary expansion treatment, root
resorption always occurs unavoidably. In this study, the
tissue-borne MARPE appliances only receive support
from screws placed in the palatal region instead of
receiving support from natural teeth. We hope such a
design can decrease the undesirable dental side effects
during maxillary expansion, such as buccal tipping,
gingival recession, and root resorption, by eliminating
expansion forces from the tooth support.
The root volume loss occurred in all anchorage teeth
in the tooth-borne group and U6, U5, and U4 in the
tissue-borne group. In addition, the decreased root vol-
ume was significantly more in the tooth-borne group
than in the tissue-borne group, except for the U6P,
U2, and U1. This indicates more obvious root resorption
in the anchorage teeth, as the amount of root resorption
occurring was directly associated with the amount of
root movement within the bone.34 In addition, no statis-
tically significant differences were found in root resorp-
tion on the U6P between the experimental groups; it is
likely because the U6P surface was the least affected
by the expansion force. The reason for the different
resorption in buccal roots may be that the force was
applied to the tooth in the buccal direction. At this
time, compression force occurs on the surfaces of buccal
roots, and root resorption may occur during the elimina-
tion of the hyalinization tissue on the compressed side.35
These results confirm the hypotheses of the design
concept of our bone-borne MARPE appliances.
It has been observed through histologic studies that 3
months after the end of the maxillary expansion, the
cementum of the anchorage premolars would be re-
paired.36 Dindaro glu and Dogan31 also found cementum
repair in the absorbed socket holes on the root surface
- 2023  Vol -  Issue -
Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
after maintaining expansion appliances for 6 months,
which indicated root resorption caused by maxillary
expansion is reversible to some extent. Therefore, we
recommend maintaining about 6 months after RME.
On the one hand, it can maintain the enlarged maxilla
and arch state; on the other hand, the risk of root resorp-
tion may be avoided to the greatest extent.
CONCLUSIONS
1. Tooth-borne MARPE (group B) and tissue-borne
MARPE (group A) produced the same maxillary
and arch width expansion efficiency.
2. Group B showed 58.5% more alveolar bone loss on
the first molar (U6) and 29.1%, 34.6%, and 21.0%
more root volume loss on premolar and molar area
(U4, U5, U6) than those in group A.
3. This research could not produce long-term data
regarding possible reversible repair of the root vol-
ume loss caused by maxillary expansion after a
6-month stabilizing expansion appliance.
ACKNOWLEDGMENTS
The authors thank the cooperation of all the patients
for their contribution to the study. In addition, the au-
thors thank the School and Hospital of Xiangya Stoma-
tology, Central South University, for providing
equipment.
AUTHOR CREDIT STATEMENT
Ruoyu Ning contributed to conceptualization, study
design, original draft preparation, and manuscript re-
view and editing; Junjie Chen contributed to investiga-
tion, formal analysis, original draft preparation, and
manuscript review and editing; Siling Liu contributed
to investigation, original draft preparation, and manu-
script review and editing; and Yanqin Lu contributed
to conceptualization.
REFERENCES
1. MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W.
The effects of micro-implant assisted rapid palatal expansion
(MARPE) on the nasomaxillary complex–a finite element method
(FEM) analysis. Prog Orthod 2014;15:52.
2. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution of
selected occlusal characteristics in the US population, 1988-
1991. J Dent Res 1996;75(Spec No):706-13.
3. Kutin G, Hawes RR. Posterior cross-bites in the deciduous and
mixed dentitions. Am J Orthod 1969;56:491-504.
4. Brunetto DP, Sant’Anna EF, Machado AW, Moon W. Non-surgical
treatment of transverse deficiency in adults using microimplant-
assisted rapid palatal expansion (MARPE). Dental Press J Orthod
2017;22:110-25.
American Journal of Orthodontics and Dentofacial Orthopedics
Ning et al
5. Capelozza Filho L, Cardoso Neto J, da Silva Filho OG, Ursi WJ.
Non-surgically assisted rapid maxillary expansion in adults. Int J
Adult Orthod Orthognath Surg 1996;11:57-66.
6. Lo Giudice A, Barbato E, Cosentino L, Ferraro CM, Leonardi R.
Alveolar bone changes after rapid maxillary expansion with
tooth-born appliances: a systematic review. Eur J Orthod 2018;
40:296-303.
7. Pham V, Lagravere MO. Alveolar bone level changes in maxillary
expansion treatments assessed through CBCT. Int Orthod 2017;
15:103-13.
8. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G. Tooth-borne
vs bone-borne rapid maxillary expanders in late adolescence.
Angle Orthod 2015;85:253-62.
9. Chen JJ, Xu YH, Li CR, Zhang L, Yi F, Lu Y. Displacement and stress
distribution of the craniomaxillofacial complex under different
surgical conditions: a three-dimensional finite element analysis
of fracture mechanics. BMC Oral Health 2021;21:596.
10. Choi SH, Shi KK, Cha JY, Park YC, Lee KJ. Nonsurgical miniscrew-
assisted rapid maxillary expansion results in acceptable stability in
young adults. Angle Orthod 2016;86:713-20.
11. Moon W. Class III treatment by combining facemask (FM) and
maxillary skeletal expander (MSE). Semin Orthod 2018;24:95-107.
12. Yildirim M, Akin M. Comparison of root resorption after bone-
borne and tooth-borne rapid maxillary expansion evaluated with
the use of microtomography. Am J Orthod Dentofacial Orthop
2019;155:182-90.
13. Mutinelli S, Cozzani M, Manfredi M, Bee M, Siciliani G. Dental arch
changes following rapid maxillary expansion. Eur J Orthod 2008;
30:469-76.
14. Chen HY, Liu LW, Han MX, Gu Y, Wang W, Sun L, et al. Changes of
maxillary central incisor and alveolar bone in Class II Division 2
nonextraction treatment with a fixed appliance or clear aligner:
a pilot cone-beam computed tomography study. Am J Orthod
Dentofacial Orthop 2023;163:509-19.
15. Ugolini A, Cerruto C, Di Vece L, Ghislanzoni LH, Sforza C,
Doldo T, et al. Dental arch response to Haas-type rapid maxil-
lary expansion anchored to deciduous vs permanent molars: a
multicentric randomized controlled trial. Angle Orthod 2015;
85:570-6.
16. Fleiss JL. Analysis of covariance and the study of change. The
design and analysis of clinical experiments. New York: John Wiley
& Sons, Inc; 1999, p. 186-219.
17. Alcin R, Malko S. Does mini-implant-supported rapid maxillary
expansion cause less root resorption than traditional approaches?
A micro-computed tomography study. Korean J Orthod 2021;51:
241-9.
18. Ronsivalle V, Casella F, Fichera G, Bennici O, Conforte C, Lo
Giudice A. Root resorption of maxillary posterior teeth after rapid
maxillary expansion: a comprehensive review of the current evi-
dence from in-vitro and in-vivo studies. Open Dent J 2021;15:
97-101.
19. Wınsauer H, Vlachojannıs J, Wınsauer C, Ludwıg B, Walter A. A
bone-borne appliance for rapid maxillary expansion. J Clin Orthod
2013;47:375-81; quiz 388.
20. Carlson C, Sung J, McComb RW, Machado AW, Moon W. Microim-
plant-assisted rapid palatal expansion appliance to orthopedically
correct transverse maxillary deficiency in an adult. Am J Orthod
Dentofacial Orthop 2016;149:716-28.
21. Giuca MR, Pasini M, Galli V, Casani AP, Marchetti E, Marzo G. Cor-
relations between transversal discrepancies of the upper maxilla
and oral breathing. Eur J Paediatr Dent 2009;10:23-8.
American Journal of Orthodontics and Dentofacial Orthopedics
Descargado para Anonymous User (n/a) en Cayetano Heredia Pervuvian University de ClinicalKey.es por Elsevier en junio 30, 2023. Para uso
personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
9
22. Oliveira De Felippe NL, Da Silveira AC, Viana G, Kusnoto B,
Smith B, Evans CA. Relationship between rapid maxillary expan-
sion and nasal cavity size and airway resistance: short- and
long-term effects. Am J Orthod Dentofacial Orthop 2008;134:
370-82.
23. Garib DG, Henriques JF, Janson G, Freitas MR, Coelho RA. Rapid
maxillary expansion-tooth tissue-borne versus tooth-borne ex-
panders: a computed tomography evaluation of dentoskeletal ef-
fects. Angle Orthod 2005;75:548-57.
24. Kanomi R, Deguchi T, Kakuno E, Takano-Yamamoto T,
Roberts WE. CBCT of skeletal changes following rapid maxillary
expansion to increase arch-length with a development-
dependent bonded or banded appliance. Angle Orthod 2013;83:
851-7.
25. Akyalcin S, Alexander SP, Silva RM, English JD. Evaluation of
three-dimensional root surface changes and resorption
following rapid maxillary expansion: a cone beam computed
tomography investigation. Orthod Craniofac Res 2015;18(Suppl
1):117-26.
26. Kim Y, Park JU, Kook YA. Alveolar bone loss around incisors in sur-
gical skeletal Class III patients. Angle Orthod 2009;79:676-82.
27. Kobayashi-Velasco S, Santos RLO, Salineiro FCS, Pinheiro LR,
Cavalcanti MGP, Lemos J unior CA. Comparison between pano-
ramic radiography and CBCT imaging on the diagnosis of second
molar external root resorption associated with an impacted
mandibular third molar: two case reports. J Dent Health Oral Dis-
ord Ther 2018;9:115-7.
28. Deng Y, Sun Y, Xu T. Evaluation of root resorption after compre-
hensive orthodontic treatment using cone beam computed to-
mography (CBCT): a meta-analysis. BMC Oral Health 2018;18:
116.
29. Xie XY, Jia SM, Sun ZH, Zhang ZY. Diagnostic accuracy of cone
beam computed tomography with different resolution settings
for external root resorption. Beijing Da Xue Xue Bao Yi Xue Ban
2019;51:75-9.
30. Hodges RJ, Atchison KA, White SC. Impact of cone-beam
computed tomography on orthodontic diagnosis and treat-
ment planning. Am J Orthod Dentofacial Orthop 2013;143:
665-74.
31. Dindaroglu F, Dogan S. Evaluation and comparison of root resorp-
tion between tooth-borne and tooth-tissue borne rapid maxillary
expansion appliances: a CBCT study. Angle Orthod 2016;86:
46-52.
32. Rosa M, Lucchi P, Manti G, Caprioglio A. Rapid palatal expansion
in the absence of posterior cross-bite to intercept maxillary incisor
crowding in the mixed dentition: a CBCT evaluation of sponta-
neous changes of untouched permanent molars. Eur J Paediatr
Dent 2016;17:286-94.
33. Lo Giudice A, Galletti C, Gay-Escoda C, Leonardi R. CBCT assess-
ment of radicular volume loss after rapid maxillary expansion: a
systematic review. J Clin Exp Dent 2018;10:e484-94.
34. Segal GR, Schiffman PH, Tuncay OC. Meta analysis of the
treatment-related factors of external apical root resorption. Or-
thod Craniofac Res 2004;7:71-8.
35. Brezniak N, Wasserstein A. Orthodontically induced infiammatory
root resorption. Part I: the basic science aspects. Angle Orthod
2002;72:175-9.
36. Martins DC, Souki BQ, Cheib PL, Silva GA, Reis ID, Oliveira DD,
et al. Rapid maxillary expansion: do banded teeth develop more
external root resorption than non-banded anchorage teeth? Angle
Orthod 2016;86:39-45.
- 2023  Vol -  Issue -