ORIGINAL ARTICLE

Analysis of factors associated with the

success of microimplant-assisted rapid
palatal expansion
Carolina Marques Meirelles,a Rafael Malagutti Ferreira,a Hideo Suzuki,b Cibele Braga Oliveira,c
Adriana Souza de Jesus,d Aguinaldo Silva Garcez,e and Selly Sayuri Suzukib
Campinas and Araraquara, S~ao Paulo, and Jo~ao Pessoa, Paraıba, Brazil

Introduction: Success-related factors of microimplant-assisted rapid palatal expansion (MARPE) were

evaluated, including age, palatal depth, suture, and parassutural bone thickness, suture density and
maturation, and the relation to corticopuncture (CP) technique, as well as skeletal and dental effects.
Methods: Sixty-six cone-beam computed tomography scans were analyzed before and after rapid maxillary
expansion procedures in 33 patients aged 18-52 years for both sexes. The scans were generated in digital
imaging and communications in medicine file format and analyzed in the multiplanar reconstruction of the
regions of interest. Palatal depth, suture thickness, density and maturation, age, and CP were assessed. To
evaluate dental and skeletal effects, the sample was divided into 4 groups: successful MARPE (SM), SM 1
CP technique (SMCP), failure MARPE (FM), and FM 1 CP (FMCP). Results: Successful groups presented
more skeletal expansion and dental tipping than failure groups (P \0.05). The mean age of the FMCP group
was significantly higher than the SM groups; suture and parassutural thickness significantly related to the suc-
cess, and patients who received CP showed a success rate of 81.2% compared with 33.3% in the no CP group
(P \0.05). Suture density and palatal depth did not show a difference between the success and failure groups.
Suture maturation was higher in SMCP and FM groups (P \0.05). Conclusions: Older age, thin palatal bone,
and higher stage of maturation can influence the success of MARPE. CP technique in these patients appears
to have a positive impact, increasing the chance of treatment success. (Am J Orthod Dentofacial Orthop
2023;164:67-77)

I
ndications for microimplant-assisted rapid palatal supported rapid expansion, such as a decrease in alveolar
expansion (MARPE) include patients at the end of bone thickness and height, bone dehiscence, and
their growth phase and adult patients with maxillary gingival recession that may occur as a result of forces
transverse deficiency as an alternative to avoid surgical placed on the teeth and their supporting structures.
intervention.1,2 MARPE technique can potentially Cone-beam computed tomography (CBCT) data were
reduce undesirable effects from conventional tooth- recently introduced to evaluate craniofacial structures
for a more accurate diagnosis and prognosis of maxillary
expansion, such as midpalatal suture maturation stage
a
Department of Post-graduation in Orthodontics, Faculdade S~ao Leopoldo Man-
and density, midpalatal suture thickness, and
dic, Campinas, S~ao Paulo, Brazil.
b
Department of Orthodontics, S~ao Leopoldo Mandic School and Dental Institute, morphology of the zygomatic process of the maxilla.3-7
Campinas, S~ao Paulo, Brazil. Moreover, the regional acceleratory phenomenon
c
Private practice; Faculdade COESP, Jo~ao Pessoa, Paraıba, Brazil.
d induced by surgical trauma, acting directly on bone re-
Department of Orthodontics, School of Dentistry, S~ao Paulo State University,
Araraquara, S~ao Paulo, Brazil. modeling, and accelerating tooth movement, has been
e
Department of Oral Microbiology, Faculdade S~ao Leopoldo Mandic, Campinas, advocated. Some surgical techniques have been pro-
S~ao Paulo, Brazil.
posed, such as corticotomy, corticision, piezopuncture,
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported. microosteoperforation, and corticopuncture (CP).
Address correspondence to: Carolina Marques Meirelles, Department of Post- Although the MARPE technique potentially represents
graduation in Orthodontics, Faculdade S~ao Leopoldo Mandic, Rua Jose Rocha
a nonsurgical alternative to treating maxillary constric-
Junqueira 13, Campinas, S~ao Paulo 13045-755, Brazil; e-mail, carolina.
marques.meirelles@hotmail.com. tion, it may not be as predictable in older adult patients
Submitted, November 2021; revised and accepted, October 2022. because of increased interdigitation of the midpalatal
0889-5406/$36.00
suture with aging.8,9 CP is a bone trauma performed
Ó 2023 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2022.10.029 by surgical intervention, usually limited to the cortical

67

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68
Fig 1. A, SL model expander supported on 4 mini-implants (Peclab); B, MSE model expander sup-
ported on 4 mini-implants (MSE, Biomaterials Korea).
portion of the alveolar bone. This technique has been
associated with treating MARPE to reduce resistance
and optimize the opening.10 This study analyzed
possible factors associated with the success of MARPE,
such as the auxiliary technique of CP, midpalatal suture
bone density and maturation, and midpalatal and para-
ssutural bone thickness performed in adult patients.
Dental and skeletal responses were also analyzed,
considering palatal bone expansion and tooth tipping
measurements.
MATERIAL AND METHODS
This study was approved by the Ethics Committee of
S~ao Leopoldo Mandic School and Dental Institute (refer-
ence no. 3.323.906). Ethical approval was obtained on
May 14, 2019. The reference number of the General
Ethics Commission site of the Brazilian Government is
CAAE 12739119.2.0000.5374.
For this retrospective study, 66 CBCT scans were
selected from the records of 33 people aged 18-52 years
treated between 2017 and 2020. Data were collected
before and up to 3 months after expansion therapy, ac-
cording to the study by Storto et al.11
The inclusion criteria were patients with transverse
maxillary deficiency treated with MARPE in the clinic
of the Postgraduation in Orthodontics Course at
Faculdade S~ao Leopoldo Mandic. Exclusion criteria
were patients with a history of periodontal disease, pre-
vious orthodontic treatment, patients with congenital
malformations, and patients with a period of .6 months
between the initial CT scan and the beginning of ortho-
dontic treatment.
CBCT scans used in this study were obtained using
the I-CAT scanner (Imaging Sciences International, Hat-
field, Pa) before (T0) and after (T1) expansion, using the
following parameters: 36 mA, 120 kVp, exposure time of
36 seconds, voxel size of 0.25 mm, and scanning area of
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Meirelles et al
16 3 13. The images were saved in digital imaging and
communication in medicine file format and examined
using Horos software (version 2.3.0; Horos Project, An-
napolis, Md) and OnDemand 3D (Cybermed, Seoul,
South Korea).
MARPE procedure was performed using the
following expanders: SL model expander supported by
4 mini-implants (Peclab, Belo Horizonte, Brazil) or
maxillary skeletal expander and 4 mini-implants (maxil-
lary skeletal expander [MSE]; Biomaterials Korea, Seoul,
South Korea). Criteria for clinical positioning of the
MARPE appliance considered the positioning of the 2
anterior mini-implants in a region of the palatal curve
(behind the third palatal rugae) in which greater bone
thickness was available and the expander was kept as
horizontal as possible (Fig 1). Maxillary expansion proto-
col included immediate start after MARPE insertion,
except for the group of patients who received CP along
the midpalatal suture, on which 1 week was needed for
mucosa healing. The activation protocol used was 2 ac-
tivations/d (0.4 mm/d)1,11 until the maxillary skeletal
width was equal to or greater than the mandibular width
(lasted about 2-3 weeks).5
Patients who underwent CP facilitating procedure
were aged $24 years, and microperforations were
performed in the midpalatal suture region using a
1.5-mm diameter Peclab bur with a 6-mm active tip
(perforation depth) according to the method described
by Suzuki et al (Fig 2).10
Sample distribution can be found in Table I. Patients
treated successfully with MARPE without performing the
CP technique (SM; n 5 10), successfully treated with
MARPE and the adjunct CP technique (SMCP; n 5 13),
failure group with no midpalatal suture opening without
performing the CP technique (FM; n 5 4), and failure
group with no midpalatal suture opening adjunct CP
technique (FMCP; n 5 6). The initial transverse maxillary
discrepancy between the groups did not show a
American Journal of Orthodontics and Dentofacial Orthopedics
Meirelles et al 69

Fig 2. CP auxiliary technique performed in the midpalatal suture region.

Table I. Sample distribution

Total sample (n 5 33) Age, y Female, % Male, % TMD, mm DTm,  AP PP
SM (n 5 23)
NCP (n 5 10) 20.0 6 6.0a 60 40 4.3 6 1.3 3.34 6 0.82a 2.29 6 0.98a 1.87 6 0.60a
CP (n 5 13) 34.0 6 6.4b 80 20 4.2 6 0.5 3.82 6 2.19a 2.60 6 1.13a 2.09 6 0.53a
FM (n 5 10)
NCP (n 5 4) 34.0 6 4.6b,c 50 50 4.6 6 1.4 3.92 6 2.84a 0.00 6 0.00b 0.17 6 0.21b
CP (n 5 6) 43.0 6 9.0c 50 50 4.9 6 1.5 3.89 6 2.72a 0.11 6 0.13b 0.18 6 0.32b
Note. Values are mean 6 standard deviation. The difference between groups is represented by distinct superscripted letters (P \ 0.05). Significance
was determined using the Student t test and analysis of variance followed by the Tukey post-hoc test. Dental tipping ( ) measurement is defined by
the mean inclination values of the maxillary first molars on the right and left sides and bone palate expansion (mm).
TMD, mean initial transverse maxillary discrepancy; DTm, dental tipping molar; AP, distance lateral walls of the incisive foramen; PP, distance
lateral walls between the greater palatine foramina.

significant difference (P \0.05), and the mean values
described in the table refer to both sides12 (Table I).
The FM and FMCP groups were represented by patients
in which the maxillary expansion on the palate was \1
mm and clinically did not present a diastema.
Before measurements, images were aligned
previously in a standard manner as follows (Fig 3), in
the coronal section of the nasion-anterior nasal spine
(N-ANS) and the sagittal and axial section of the anterior
nasal spine-posterior nasal spine (ANS-PNS).11,13
Skeletal and dental effects were assessed in all groups
before and after expansion, and values are presented
in Tables II, III, and Figure 4.
SM and SMCP groups showed significantly greater
palatal expansion, a measurement taken by the
distance lateral walls of the incisive foramen and
distance lateral walls between the greater palatine
foramina, whereas, in the FM group, no change was
observed. No significant differences between SM and
SMCP groups were found in skeletal expansion. After
expansion, all groups showed a significant increase in
dental inclination in the region of the first molars.
No statistical differences in dental tipping were found
between groups (Table I).
Midpalatal suture and parassutural thickness
measures were taken perpendicular to the reference line
(from the incisive foramen to the posterior nasal spine)
in the sagittal view at the regions of the second premolars
and first molars. In addition, parassutural measurements
were performed 3 mm away from the midpalatal suture
on the right and left sides,4,17,20 as shown in Figure 5.
Both measurements were taken at T0 and T1 to compare
the result of treatment in each studied group. Palatal
depth was measured using as a reference the functional
occlusal plane up to the uppermost point of the palate
at coronal view19 (Fig 6). Midpalatal suture density was
defined using Horos software through an equation with
bone density values in the region of the palatal suture,
soft palate, and palatal process of the maxilla. In addition,
the maturation stage of the midpalatal suture was defined
by 4 different stages of suture maturation (A-E) in the
axial section.3,15,16
Statistical analysis
Analysis of variance test with an a of 0.80, power of
0.25 effect size was performed, resulting in a total sam-
ple size of 30 (version 3.0.10, G*Power software; Franz
Faul, Universitat Kiel, Kiel, Germany).

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70 Meirelles et al

Fig 3. Images of the orientation planes from the Horos software.

Table II. Linear and angular measurements taken on CBCT scans before and after maxillary expansion
Measurement Description
Palatal expansion (mm) In the anterior region of the palate, the distance between the lateral margins of the incisive foramen
was measured. In the posterior region of the palate, the distance between the lateral margins of the
greater palatine foramen was used as a reference in the axial section14 (Fig 4)
Dental tipping ( ) Angle formed between the line passing through the long axis of the palatal root of the maxillary first
premolars with the horizontal plane determined by the base of the nasal floor, and the line of the long
axis of the palatal root of the maxillary first molars with the horizontal plane7 (the mean of the values
obtained on the right and left sides were used) (Fig 4)

Statistical tests were performed using GraphPad
Prism (version 8.0; GraphPad Software, La Jolla, Calif).
The significance level adopted for all comparisons was
P \0.05. The Shapiro-Wilk test was used to investigate
the normal distribution.
The chi-square test was used to compare groups for
midpalatal suture bone maturation and to analyze the
outcome of the auxiliary technique of CP in MARPE.
Moreover, the impact of the CP procedure and parassu-
tural bone thickness on the success of MARPE therapy
was evaluated using the binomial logistic regression
model.
For the measurements of palatal bone thickness, the
interclass correlation was performed, with a value equal
to 0.96 (excellent measurement replicability); in
contrast, for bone maturation measurements of the
midpalatal suture, the kappa test was performed to
analyze the agreement, with a value of 0.629
(substantial agreement of the measurements obtained).
A Student t test was used to analyze the values before
and after expansion in each studied group. For inter-
group analysis, the difference between the measure-
ments before and after expansion (SM, SMCP, FM, and
FMCP) was calculated, and when the assumptions of
normality were not violated, the 1-way analysis of vari-
ance analysis was performed, followed by the Tukey
posthoc multiple comparison tests, and when they
were violated, the Kruskal-Wallis nonparametric test
was performed, followed by the Dunn post-hoc multiple
comparison test.
In addition, Pearson and Spearman correlation
coefficient tests were used to evaluate the correlation
between density, thickness, and maturation.
RESULTS
A total success rate of midpalatal suture opening of
70% was observed. The CP group of patients showed
an 80% success rate compared with a 53.8% success
rate when no CP was performed (Table IV).
When patients were divided into 2 categories: thick
palate (.2 mm posterior) and thin palate (#2 mm
posterior), was observed a significant relationship in
patients with a thin palate (n 5 22) that received
microperforations (CP) associated with MARPE and the
success of the treatment (81.2% of success rate). In
patients with a thick palate (n 5 11), no significant
relationship was observed between CP and outcome
(Table IV). Furthermore, binominal logistic regression
analysis was used to predict outcomes with/without
CP associated with MARPE and parassutural bone
thickness. Both factors were found to be able
to predict the outcome of the treatment (P \0.05)
(Table V).
A significant difference was observed between the
SM and SMCP groups and the FM group for the midpa-
latal and parassutural bone thickness. Both success
groups (SM and SMCP) showed a significantly thicker
palate than the failure group (FM), which presented a
thinner palate, especially at the parassutural area of
premolars and molars (Fig 7).

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Table III. Predictive factors evaluated in the initial CBCT scans

Factor
CP auxiliary technique
Maturation stage of the
midpalatal suture
Midpalatal suture density
(ratio calculated by gray shade)
Midpalatal bone thickness (mm)
Parassutural bone thickness (mm)
Palatal depth (mm)
Description
Microperforations (6 mm depth) were performed in the region of the midpalatal suture
every 2 mm along the suture10 (Fig 2).
Defined by 4 different stages of suture maturation (A-E) in the axial section, described
by Angelieri et al3,15,16
Defined using Horos software, through an equation with bone density values in the region
unheid et al6,17
of the palatal suture, soft palate, and palatal process of the maxilla, described by Gr€
Measurements were taken perpendicular to a line drawn from the incisive foramen to the posterior nasal
spine, in midpalatal suture cuts, in the region of the maxillary second premolars and first molars4,18
Measurements were taken perpendicular to a line drawn from the incisive foramen to the posterior nasal
spine, 3 mm lateral to the midpalatal suture to the right and left in the region of the maxillary second
premolars and first molars4
Distance from the functional occlusal plane to the uppermost point of the palate in the region of
the maxillary second premolars and first molars19

Fig 4. A, Measurement of dental tipping on the coronal view (using the first premolars and first molars
as a reference); B, Measurements of palatal bone expansion, using the incisive foramen as an anterior
reference and the palatine foramen as a posterior reference, on the axial section.

Palatal depth, midpalatal suture bone thickness,
and parassutural bone thickness were measured, and
values were compared between groups (Table VI;
Fig 7). Palatal depth was not related to the success
of the expansion with MARPE, as no significant
differences were found between the success and
failure groups (Table VI).
Table I shows the mean age of the patients per group.
Data show that the mean age of patients in the SM group
is significantly lower than the other groups (P \0.05). In
contrast, the FMCP group showed higher mean age than
in other groups (P \0.05).
Regarding midpalatal suture bone maturation, in the
SMCP and FM groups, most of the samples were in stage
E of the sutural classification described by Angelieri
et al.3 A statistical difference (P \0.05) was observed
in the distribution of the sample in the stages of bone
maturation between the SM group and the SMCP and
FM groups; no statistical differences were found for
the SMCP and FM groups (Table VII).
In evaluating midpalatal suture bone density,
no significant differences were found between
success with and without CP and failure groups
(Table VIII).

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72 Meirelles et al

Fig 5. A, Measurement of the midpalatal suture thickness, taken perpendicular to the reference line, in
the sagittal section, in the maxillary second premolar region. B, Measurement of the parassutural bone
thickness, taken perpendicular to the reference line, in the sagittal section, 3 mm on the left side, in the
maxillary second premolar region.

Finally, a correlation between midpalatal suture bone

density and maturation did not show a significant
correlation between these variables. A significant nega-
tive correlation was observed between bone density and
thickness of the midpalatal suture (weak to moderate),
showing that the higher the density, the lower the suture
thickness. When comparing the variables of suture
maturation and thickness, a significant negative correla-
tion of weak to moderate was found; therefore, the
greater the bone maturation, the lower the midpalatal
thickness (Table IX).

DISCUSSION
In this study, successful treatment with MARPE was
defined as patients with at least 1 mm of midpalatal
suture opening. The SM group showed a significant
increase (posterior region) in suture opening of
1.87 mm in the first molar region, compared with the
FM groups, which did not show any significant suture
Fig 6. Palatal depth measurement was performed in the opening. The SMCP group showed a significant increase
coronal section. in suture opening (posterior region) of 2.09 mm in the

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Meirelles et al 73

Table IV. Association of CP auxiliary technique in MARPE when patients were divided into 2 groups according to
bone thickness
Outcome

Intervention Failure, n Success, n Total, n P value Success rate, %

Total
No CP 4 7 11 0.110 53.8
CP 6 16 22 80.0
Total 10 23 33 70.0
Thin (#2 mm posterior)
No CP 4 2 6 0.032* 33.3
CP 3 13 16 81.2
Total 7 15 22 68.1
Thick (.2 mm posterior)
No CP 2 5 7 0.898 71.4
CP 1 3 4 75.0
Total 3 8 11 72.2

*Statistically significant difference as determined by c2 test (P \0.05).

observe significant tooth tipping after expansion, with

Table V. Binominal logistic regression model for as-
sessing the impact of the CP procedure and parassu-
tural bone thickness on the MARPE successful
treatment
Odds ratio
Predictor (95% confidence interval)
CP - no CP 7.15 (1.05-48.23)
Parassutural bone 5.22 (1.03-26.36)
thickness, mm
*Statistically significant difference (P \0.05).
first molar region, with no statistical differences
compared with the SM group. These results were similar
to those observed in the study by Oliveira et al,14 that ob-
tained a palatal expansion of approximately 2.5 mm in
the posterior region in the successful midpalatal suture
opening group in patients aged up to 29 years. Their re-
sults were different from the results of Storto et al,11
which showed a palatal suture opening of 4 mm in the
posterior region because the sample in this study was
older than the one used by Storto et al.11
The successful and failure groups showed a mild
increase in buccal dental tipping in the first molar region
(SM, 3.34 ; SMCP, 3.82 ; FM, 3.92 ; FMCP, 3.89 ). The
result of this study was similar to that obtained by Park
et al,7 whose effect of dental tipping was described as
inevitable because of the bending of the alveolar bone
by force exerted for the expansion of the palatal bone.
These authors used a different design and positioning
of the MARPE device and obtained a 5.8 increased
tipping in the molar region, which is higher than the
result obtained in this study. These results differ from
those obtained by Paredes et al,21 who used the MSE
as an expander anchored to mini-implants and did not
values of 0.09 on the right side and 0.13 on the left
side in the molars region.
The midpalatal suture bone thickness showed a
significant positive correlation with the success of
expansion with MARPE. The SM group obtained a value
P value of 5.2 mm of parassutural thickness in the first molar
0.043* region, and this result is consistent with the study by
0.045*
Poon et al,4 in which bone thickness, volume, and
quality are important factors to be to provide better
guidelines for choosing sites to install mini-implants to
assist orthodontic treatment. It also corroborates the
study of Jesus et al,17 that describes that the success
of MARPE is related to a greater thickness of the
midpalatal suture, with values of at least 5 mm. The
authors discuss that, although there is possibly greater
resistance of the midpalatal suture in the successful
group, the greater thickness of the palate should favor
the primary stability of the mini-implants and the
consequent improvement in the anchorage of the
MARPE expander, which may contribute to the success
of this treatment. However, the primary stability of the
mini-implants was not measured.
In this study, the parassutural bone thickness was
measured, and it was observed that the SM and SMCP
groups showed a greater thickness of the parassutural
region than the FM group. Several studies18,20,22
associated palatal bone thickness with the success of
mini-implants and therefore indicate that areas of
greater thickness as the most appropriate for their
insertion. The parassutural thickness (2-4 mm lateral
to the suture) is thicker in the anterior region (premolars)
than the posterior areas (first and second molars) in both
males and females, with mean values range of 3-4 mm in
the anterior region and \3 mm in the posterior region.

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74 Meirelles et al

Fig 7. Midpalatal and parassutural palatal suture bone thickness is observed in the SM, SMCP, and
failure MARPE groups in the maxillary second premolar and first molar regions. SM, successful
MARPE; SMCP, successful MARPE 1 corticopuncture; MARPE, microimplant-assisted rapid palatal
expansion.

Table VII. Comparison of midpalatal suture bone

Table VI. Comparison of palatal depth measurements
maturation between the groups
between the groups (mm)
Midpalatal suture bone maturation, %
Palatal depth
Groups A B C D E Difference
Comparison Comparison b
Groups Premolar between groups Molar etween groups SM 0 0 30 40 30 A*
SMCP 0 0 20 15 65 B
SM 23.6 6 3.12 A 21.9 6 2.70 A
FM 0 0 0 30 70 B
SMCP 24.8 6 2.73 A 23.5 6 1.94 A
FM 24.6 6 1.98 A 22.9 6 1.46 A Note. Differences between groups are represented by distinct letters
(ie, A and B).
Note. Statistical significance was determined by an analysis of vari-
SM, successful MARPE; SMCP, successful MARPE 1 corticopunc-
ance test followed post-hoc Tukey test (P\0.05). The difference be-
ture; FM, failure MARPE.
tween groups is represented by distinct letters.
*Statistical significance was determined by c2 test (P 5 0.03).
SM, successful MARPE; SMCP, successful MARPE 1 corticopunc-
ture; FM, failure MARPE.
parassutural areas in the anterior region, considered
the most appropriate region for mini-implants
Therefore, they contraindicate regions of low bone installation. Furthermore, the later study highlighted
thickness for mini-implant placement because of poor that sex and ethnicity should also be considered in
primary stability. The results of this study indicate that planning because of significant differences in palatal
patients with thin parassutural bone may have thickness in relation to these variables.
compromised mini-implant primary stability and, In this study, palatal depth was not related to the
therefore, a higher risk of failure when applying heavy success of the expansion, as no significant differences
forces resulting from expansion, particularly when the were found in the values between the success and failure
bone thickness is \2 mm in both anterior and posterior groups (21.9, 23.5, and 22.9 mm, respectively). In the
regions. In addition, whenever bicortical anchorage of article by Hwang et al,19 correlation was found between
the mini-implant is achieved, more stability, less palatal height measurement and facial patterns, and a
possibility of deformation or fracture, and a more trend toward narrower arches, thinner alveolar bones
parallel and efficient expansion.23 These factors should and higher palatal heights was observed because
be considered when planning the best place for patients had more vertical growth patterns, with values
mini-implant insertion. These results are consistent of 20.03 mm for females and 20.83 mm for males.
with a study by Yasushi et al24 that observed thicker According to Shin et al,25 mean palatal depth value of

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Meirelles et al
Table VIII. Comparison of midpalatal suture bone
density between the groups
Midpalatal suture
Groups bone density Significance
SM 0.61 6 0.13 NS
SMCP 0.79 6 0.09
FM 0.70 6 0.12
Note. Values are presented as mean 6 standard deviation. Statistical
significance was determined by an analysis of variance test
(P \0.05).
NS, no significant difference; SM, successful MARPE; SMCP, suc-
cessful MARPE 1 corticopuncture; FM, failure MARPE.
Table IX. Correlation between bone density, bone
maturation, and thickness of the palatal suture
Variables Density Maturation Thickness
Density –
Maturation 0.225 (0.087) –
Thickness 0.326* (0.035) 0.423* (0.005) – stage and thickness with bone density. No significant
Values are Pearson r values.
*Statistically significant difference (P \0.05) as determined by Pear-
son and Spearman correlation coefficient tests.
10.33 mm was found for premolars and 14.33 mm for
molars, and this variable did not show a significant
correlation with the success of MARPE.
According to Angelieri et al,3 assessment of the
midpalatal suture maturation stage in the initial CBCT
scan is a reliable parameter for choosing the palatal
expansion treatment for the patient. The results of this
study found no significant differences in the maturation
stage of the suture between the SMCP and FM groups. In
these groups, most of the sample was in stage E of bone
maturation. However, a difference was found when
comparing these groups with the SM group, probably
because of the significant difference in mean age
between the SMCP and FM groups (34 and 39 years,
respectively) and the SM group (20 years). This result
was similar to that found in the study by Shin et al,25
in which the authors observed that age and palate
maturation stage might be predictive factors of the
success of midpalatal suture expansion with MARPE in
young adults. A previous study by Oliveira et al14 showed
that treatment success rate decreased with increasing
maturation of the midpalatal suture, with a 100%
success rate in stages B and C, 62.5% in stage D, and
58.3% in stage E. Jesus et al17 pointed out that most
patients who failed treatment with MARPE were in stage
E of bone maturation. Therefore, the CP method can be
indicated in older patients, who are more likely to
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75
present a more advanced stage of maturation, and,
therefore, its application can increase the chances of
treatment success.
Bone density did not show any association with the
success of the expansion, as no significant differences
were found in the density values of the different groups
in this study. Our result differs from the results obtained
by Gr€unheid et al,6 as they suggested that the midpalatal
suture density has a significant negative correlation with
the amount of maxillary expansion using Hyrax devices
in patients with a mean age of 12.9 years. However, it
corroborates the results of Jesus et al,17 as their study
did not find the relevance of bone density to the success
of treatment with MARPE in patients with a mean age of
23 years (success, 0.73; failure, 0.78). Titus et al26 also
observed that bone density did not significantly correlate
with the amount of palatal suture opening.
The results showed a significant negative correlation
(weak to moderate) between thickness and maturation
correlation was found between the maturation stage
and density. Given the possibility that the predictive
factors analyzed can be related (ie, a thin midpalatal
suture), the main configuration done by cortical bone
may tend to show greater density and a more compact
bone, with a tendency of not showing a line demarcating
the separation of the 2 halves of the maxilla, thus greater
midpalatal suture maturation. In contrast, patients with
greater midpalatal suture thickness tend to have a
trabecular bone (less dense and compact) between the
well-defined cortical bones of the palatal bone and nasal
floor structures, and consequently, on CBCT sections will
probably show less density and interdigitation.27
Therefore, the midpalatal suture thickness may be
related to the perception of the maturation stage and
density obtained.
The MARPE technique has been widely used because
it presents greater skeletal results and minimizes side
effects in adults. As described by previous studies, the
success rate of MARPE is quite relevant in adults,
ranging from 84.2% to 86.96%.7,28 Thus, with the
growing demand, greater predictability is necessary to
obtain the expected result of the expansion. It is
essential to analyze the factors associated with the
success or failure of the midpalatal suture opening to
understand its limitations better. The present study
observed that using auxiliary and complementary
methods to the MARPE technique, such as CP, seems
to increase MARPE success in patients showing thin
and parassutural bone thickness because it may help
weaken the highly interdigitated suture presented in
older adult patients. Further studies with a larger and
July 2023  Vol 164  Issue 1
76
more homogeneous sample group in their age range are
warranted to help individualize planning.
According to Park et al,7 morphology of the zygo-
matic process of the maxilla is a possible determining
factor of the success of MARPE. In a future study, quan-
tifying or measuring the thickness of the infrazygmatic
crest could add more insight into predictive features
regarding MARPE success. It may also be recommended
a more customized expander design individualizes the
position of the miniscrews in areas of greater bone thick-
ness, such as the T-zone anterior area.22,29-31
CONCLUSIONS
Older age, thin palatal bone, and more advanced
stages of maturation can compromise the success of
MARPE. The auxiliary technique of CP positively
impacted the success of older patients with a more
advanced stage of suture maturation and thin palatal
bone thickness.
AUTHOR CREDIT STATEMENT
Carolina Marques Meirelles contributed to investiga-
tion, formal analysis, and original draft preparation; Ra-
fael Malagutti Ferreira contributed to investigation and
formal analysis; Hideo Suzuki contributed to conceptu-
alization; Cibele Braga Oliveira contributed to manu-
script review and editing; Adriana Souza de Jesus
contributed to formal analysis; Aguinaldo Silva Garcez
contributed to formal analysis and orignal draft prepara-
tion; and Selly Sayuri Suzuki contributed to formal anal-
ysis and manuscript review and editing.
REFERENCES
1. Suzuki H, Moon W, Previdente LH, Suzuki SS, Garcez AS,
Consolaro A. Miniscrew-assisted rapid palatal expander (MARPE):
the quest for pure orthopedic movement. Dental Press J Orthod
2016;21:17-23.
2. 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.
3. Angelieri F, Cevidanes LH, Franchi L, Gonçalves JR, Benavides E,
McNamara JA Jr. Midpalatal suture maturation: classification
method for individual assessment before rapid maxillary expan-
sion. Am J Orthod Dentofacial Orthop 2013;144:759-69.
4. Poon YC, Chang HP, Tseng YC, Chou ST, Cheng JH, Liu PH, et al.
Palatal bone thickness and associated factors in adult miniscrew
placements: a cone-beam computed tomography study. Kaoh-
siung J Med Sci 2015;31:265-70.
5. Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C,
Pan HC, Miller J, et al. Changes in the midpalatal and pterygopa-
latine sutures induced by micro-implant-supported skeletal
expander, analyzed with a novel 3D method based on CBCT imag-
ing. Prog Orthod 2017;18:34.
July 2023  Vol 164  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
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personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
Meirelles et al
6. Gr€unheid T, Larson CE, Larson BE. Midpalatal suture
density ratio: a novel predictor of skeletal response to rapid
maxillary expansion. Am J Orthod Dentofacial Orthop 2017;
151:267-76.
7. Park JJ, Park YC, Lee KJ, Cha JY, Tahk JH, Choi YJ. Skeletal and
dentoalveolar changes after miniscrew-assisted rapid palatal
expansion in young adults: a cone-beam computed tomography
study. Korean J Orthod 2017;47:77-86.
8. 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.
9. Suzuki SS, Garcez AS, Reese PO, Suzuki H, Ribeiro MS, Moon W.
Effects of corticopuncture (CP) and low-level laser therapy
(LLLT) on the rate of tooth movement and root resorption in
rats using micro-CT evaluation. Lasers Med Sci 2018;33:
811-21.
10. Suzuki SS, Braga LFS, Fujii DN, Moon W, Suzuki H. Corticopunc-
ture facilitated microimplant-assisted rapid palatal expansion.
Case Rep Dent 2018;2018:1392895.
11. Storto CJ, Garcez AS, Suzuki H, Cusmanich KG, Elkenawy I,
Moon W, et al. Assessment of respiratory muscle strength and
airflow before and after microimplant-assisted rapid palatal
expansion. Angle Orthod 2019;89:713-20.
12. Lee KJ, Choi SH, Choi TH, Shi KK, Keum BT. Maxillary transverse
expansion in adults: rationale, appliance design, and treatment
outcomes. Semin Orthod 2018;24:52-65.
13. Cantarella D, Dominguez-Mompell R, Moschik C, Mallya SM,
Pan HC, Alkahtani MR, et al. Midfacial changes in the coronal
plane induced by microimplant-supported skeletal expander,
studied with cone-beam computed tomography images. Am J Or-
thod Dentofacial Orthop 2018;154:337-45.
14. de Oliveira CB, Ayub P, Ledra IM, Murata WH, Suzuki SS,
Ravelli DB, et al. Microimplant assisted rapid palatal expansion
vs surgically assisted rapid palatal expansion for maxillary trans-
verse discrepancy treatment. Am J Orthod Dentofacial Orthop
2021;159:733-42.
15. Angelieri F, Franchi L, Cevidanes LH, McNamara JA Jr. Diagnostic
performance of skeletal maturity for the assessment of midpalatal
suture maturation. Am J Orthod Dentofacial Orthop 2015;148:
1010-6.
16. Angelieri F, Franchi L, Cevidanes LHS, Gonçalves JR, Nieri M,
Wolford LM, et al. Cone beam computed tomography evaluation
of midpalatal suture maturation in adults. Int J Oral Maxillofac
Surg 2017;46:1557-61.
17. Jesus AS, Oliveira CB, Murata WH, Suzuki SS, Santos-Pinto AD.
Would midpalatal suture characteristics help to predict the success
rate of miniscrew-assisted rapid palatal expansion? Am J Orthod
Dentofacial Orthop 2021;160:363-73.
18. Wang M, Sun Y, Yu Y, Ding X. Evaluation of palatal bone thickness
for insertion of orthodontic mini-implants in adults and adoles-
cents. J Craniofac Surg 2017;28:1468-71.
19. Hwang S, Jeong S, Choi YJ, Chung CJ, Lee HS, Kim KH. Three-
dimensional evaluation of dentofacial transverse widths of adults
with various vertical facial patterns. Am J Orthod Dentofacial Or-
thop 2018;153:692-700.
20. Bonangi R, Kamath G, Srivathsa HS, Babshet M. Utility of CBCT for
the measurement of palatal bone thickness. J Stomatol Oral Max-
illofac Surg 2018;119:196-8.
21. Paredes N, Colak O, Sfogliano L, Elkenawy I, Fijany L, Fraser A,
et al. Differential assessment of skeletal, alveolar, and dental com-
ponents induced by microimplant-supported midfacial skeletal
Meirelles et al
expander (MSE), utilizing novel angular measurements from the
fulcrum. Prog Orthod 2020;21:18.
22. Kang S, Lee SJ, Ahn SJ, Heo MS, Kim TW. Bone thickness
of the palate for orthodontic mini-implant anchorage in
adults. Am J Orthod Dentofacial Orthop 2007;131
(4 Suppl):S74-81.
23. Lee RJ, Moon W, Hong C. Effects of monocortical and bicortical mini-
implant anchorage on bone-borne palatal expansion using finite
element analysis. Am J Orthod Dentofacial Orthop 2017;151:887-97.
24. Nishii Y, Sameshima GT, Mah JK, Enciso R, Takaki T, Sueishi K.
Hard palate thickness for temporary anchorage devices placement:
differences in sex and ethnicity. Orthod Waves 2014;73:121-9.
25. Shin H, Hwang CJ, Lee KJ, Choi YJ, Han SS, Yu HS. Predictors of
midpalatal suture expansion by miniscrew-assisted rapid palatal
expansion in young adults: a preliminary study. Korean J Orthod
2019;49:360-71.
26. Titus S, Larson BE, Gr€
unheid T. Midpalatal suture density ratio: assessing
the predictive power of a novel predictor of skeletal response to maxillary
expansion. Am J Orthod Dentofacial Orthop 2021;159:e157-67.
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.
77
27. Seong WJ, Kim UK, Swift JQ, Hodges JS, Ko CC. Correlations be-
tween physical properties of jawbone and dental implant initial
stability. J Prosthet Dent 2009;101:306-18.
28. Lee KJ, Park YC, Park JY, Hwang WS. Miniscrew-assisted nonsur-
gical palatal expansion before orthognathic surgery for a patient
with severe mandibular prognathism. Am J Orthod Dentofacial Or-
thop 2010;137:830-9.
29. Becker K, Unland J, Wilmes B, Tarraf NE, Drescher D. Is there an
ideal insertion angle and position for orthodontic mini-implants
in the anterior palate? A CBCT study in humans. Am J Orthod Den-
tofacial Orthop 2019;156:345-54.
30. Wilmes B, de Gabriele R, Dallatana G, Tarraf N, Ludwig B.
“Bone First” principle with CAD/CAM insertion guides for
mini-implant-assisted rapid palatal expansion. J Clin Orthod
2022;56:158-66.
31. Wilmes B, Tarraf NE, de Gabriele R, Dallatana G, Drescher D. Pro-
cedure using CAD/CAM-manufactured insertion guides for purely
mini-implant-borne rapid maxillary expanders. J Orofac Orthop
2022;83:277-84.
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