Journal of the World Federation of Orthodontists 9 (2020) S54eS58

Special Clinical Article

Miniscrew-assisted rapid palatal expansion: A review of recent

reports
Hyoung-Seon Baik a, *, Yoon-Goo Kang b, Yoon Jeong Choi a
a
Department of Orthodontics, The Institute of Craniofacial Deformity, Yonsei University College of
Dentistry, Seoul, Korea
b
Department of Orthodontics, Kyung Hee University, Seoul, Korea

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

Article history: The miniscrew-assisted rapid palatal expander (MARPE) has extended not only skeletal effects with
Received 9 August 2020 fewer dental changes and but also the age limit of nonsurgical maxillary expansion treatment. Amid its
Accepted 12 August 2020 gaining popularity in clinical orthodontics, our current understanding of treatment effectiveness, effi-
Available online 30 September 2020
ciency, and stability needs to be reassessed. In this review article, the authors have attempted to evaluate
MARPE from various aspects with a focus on recent studies.
Keywords:
Ó 2020 World Federation of Orthodontists.
Cone-beam CT
Maxillary expansion
Orthodontic anchorage
Sutures

1. Introduction
Trends in the orthodontic field since the start of the 21st century
can be characterized by the following key words: “skeletal
anchorage” and “three-dimensional tools.” Much improvements
have been made in investigational protocols, and randomized clinical
trials have now become a prominent one among these. One can easily
find sophisticated articles of systematic review and meta-analysis in
orthodontics. There were many specific trending issues on which
number of systematic reviews with and without meta-analysis exist,
such as “self-ligation brackets,” “airway issues, including sleep ap-
nea,” “computer-assisted design in orthodontic devices (e.g., Invis-
align, Incognito),” and “accelerated orthodontic tooth movement
(e.g., surgically assisted, photobiomodulation, vibration).” With
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 interest: Authors have completed and submitted the ICMJE Form for
Disclosure of potential conflicts of interest. None declared.
Provenance and peer review: Commissioned; Internally peer reviewed.
* Corresponding author: Yonsei University Dental Hospital, Room No.726, Yonsei-
ro 50-1, Seodaemun-gu, Seoul 03722, Korea.
these trends in mind, the authors looked up articles published in the
Korean Journal of Orthodontics since 2017 and could see that a certain
research topic was exceptionally quoted: miniscrew (or
microimplant)-assisted rapid palatal expansion (MARPE). The high
number of citations that the articles in this topic gathered indicated
an increase in interest in MARPE both clinically and academically.
MARPE uses skeletal anchorage for maxillary expansion (Fig. 1), and
most studies evaluating the clinical effects of MARPE adopted 3-
dimensional imaging technology (especially cone-beam computed
tomography [CBCT]) as methodology, perfectly matching the current
trend. The advent of MARPE in clinical orthodontics can be traced
back to early days after skeletal anchorage, gaining popularity in
clinical orthodontics. To the best of the authors’ knowledge, the first
literature regarding maxillary expander without dental support but
using skeletal anchorages appeared as early as 1999 [1]. Maxillary
expander with both dental and miniscrew-type skeletal anchorage
support appeared in 2010 [1], after which many studies have been
reported adding to the knowledge.
Maxillary expander or rapid palatal expander (RPE) using
skeletal anchorages can be divided into two categories: MARPE
or hybrid type and bone-borne type. It is well known that the

2212-4438/$ e see front matter Ó 2020 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2020.08.004
 H.-S. Baik et al. / Journal of the World Federation of Orthodontists 9 (2020) S54eS58
Fig. 1. MARPE. Before (top left) and after (top right) expansion, and a superimposition image of the dental cast models obtained before and after expansion (bottom).
MARPE or hybrid type uses both tooth and skeletal anchorage,
whereas bone-borne type uses only skeletal anchorage. Although
many studies have been reported, either evaluating each type of
skeletal anchorage RPE or comparing MARPE or hybrid type and
bone-borne type, treatment effects still remain controversial.
The weights of popularity in clinical orthodontics is tilted toward
the MARPE or hybrid type, and is likely due to their clinically
familiar design with conventional RPE. As Lee et al. [1] stated in
their case report, MARPE is a simple modification of the con-
ventional RPE tool, and the main difference is the incorporation
of several miniscrews. In this review article, we are aimed at
briefly assessing the current trends regarding MARPE with the
help of recently published reports and discuss the future trends
on the same.
2. Factors related to the success of MARPE
Based on histologic studies by Melsen, there is consensus that
the application of conventional RPE should be limited to patients
younger than 15 years [2,3]. Although successful palatal expansion
has been reported in young adults older than 15 years with con-
ventional RPE, in comparison most clinicians agree that MARPE has
increased the rate of success in separation of the midpalatal suture
in young adults. It is evdient from the published research reports
that MARPE had approximately 84% to 87% success rate [4e6].
Although the reports are from the same institute with identical
MARPE design, the activation protocols were slightly different (Park
et al. [5] and Lim et al. [4]: one quarter turn per day, Choi et al. [6]:
one quarter turn per 2 days). Success rate of other MARPE designs
are scarcely reported, but it is clear that there exists some cases of
failure of separation of the midpalatal suture and incidents of
asymmetric expansion because of unilateral separation of the
frontomaxillary suture [7].
Several predictors for midpalatal suture separation with MARPE
have been proposed [8]. While age, palate length, and midpalatal
suture maturation stage were negatively correlated, vertical and
sagittal skeletal pattern, midpalatal suture density ratio, and sex
S55
were reported not to be related with the suture separation [8].
Cantarella et al. [9], through retrospective analysis of 15 patients,
reported that age was not a factor for successful suture separation
using MARPE. They noticed that the pterygopalatine suture was
split after MARPE and concluded that maxillary expansion would be
limited when complete disengagement of the pyramidal process
from the pterygoid plate did not occur. In cases of asymmetric
expansion, differences in the geometry of zygomatic arches [9] and
separation of the frontomaxillary suture [7] were proposed to be
the influencing factors. Therefore, bone density, sutural maturation,
and complexity of this area could be predictors of successful
maxillary expansion.
A corticopuncture procedure along the midpalatal suture was
proposed to facilitate midpalatal sutural separation with MARPE.
Suzuki et al. [10] reported success of midpalatal suture separation
after corticopuncture in an adult patient who had previously not
found suture separation with MARPE. However, after a certain
amount of opening, resistance to expansion occurred again, which
indicated that the midpalatal suture is not the only source of
resistance. Therefore, this procedure is probably not indicated in
patients who require a larger amount of expansion.
Based on the controversial findings, the success rate of the
midpalatal suture separation and stability of the miniscrews require
further investigation. In particular, not much is known about the
stability of miniscrews used for MARPE.
3. Skeletal, dental, and facial soft tissue changes after MARPE
Conventional RPE and MARPE are both effective in widening
dental archform, although the main target patients’ ages are
different. However, many studies have shown that the extent of
skeletal changes and the nature of dental archform widening are
different. A retrospective study showed that the midpalatal suture
opening efficiency (ratio of expansion screw opening to suture
separation) for MARPE was 71% and 63% in the anterior and pos-
terior, respectively [11]. Park et al. [5] reported that maxillary
skeletal expansion accounted for 37%, whereas alveolar expansion
S56 H.-S. Baik et al. / Journal of the World Federation of Orthodontists 9 (2020) S54eS58
Fig. 2. Schematic diagram of changes in the transverse dimension after miniscrew-
assisted rapid palatal expansion.
accounted for 22% of total expansion gained by MARPE (Fig. 2).
These ratios are higher than those of the conventional RPE, which
indicates that MARPE promotes skeletal changes. The mode of
midpalatal suture separation was different from that of conven-
tional RPE. A parallel separation of the suture, 90% of anterior-
posterior ratio, was reported in contrast to conventional RPE,
which shows more opening in the anterior and less opening in the
posterior part.11 MARPE exhibited minor buccal tipping of the
maxillary molars, decrease in buccal bone thickness, and decrease
in alveolar crest level on the maxillary first molar; however, these
findings have no clinical significance [5]. Less or an equivalent
amount of periodontal effect (i.e., decrease in buccal alveolar bone
thickness and loss of crestal bone) are expected compared with
conventional RPE [12].
Fig. 3. Cone-beam computed tomography images before (white) and after (blue)
maxillary expansion. Note the pyramidal pattern of expansion of the zygomatico-
maxillary complex after MARPE with downward-forward displacement.
Extended skeletal effects of MARPE have been reported. In a
retrospective study with young adults, patients with MARPE re-
ported separation of the midpalatal suture and widening of the
maxillary bone up to zygomatic arch levels with a decrease in the
amount of expansion as it goes up (pyramidal pattern) [5]. The
other retrospective study showed similar results of the midpalatal
suture separation with an opening of the pterygopalatine suture in
16 (53%) of 30 sutures [11]. Yet another retrospective study also
reported a pyramidal pattern of expansion of the zygomaticomax-
illary complex after MARPE with downward-forward displacement
(Fig. 3) [13]. It can be concluded that most of the reports that
investigated skeletal and dental MARPE effects, including those not
mentioned previously, showed extensive skeletal effects even up to
various peri-maxillary sutures [9,14].
Studies regarding soft tissue changes with MARPE are scarce. A
retrospective study using facial scanners to investigate nasal soft
tissue change after MARPE showed a tendency for lateral, protru-
sive, and inferior movement [15]. Their results were obtained from
young adults and represented an immediate effect. The other
retrospective study using adult patients which examined more
extensive areas of the face and provided longer follow-up data
(1 year after expansion) [16] showed that paranasal area and the
medial side of the cheek exhibited most changes, and presented
with forward and outward movements. These soft tissue changes
can be connected with reported changes in maxillary position after
palatal expansion [17].
4. Stability of changes acquired with MARPE
Long-term stability reports were difficult to find. In an article
presenting 30.2  13.2 months of follow-up results, the skeletal and
dental expansion was stable with less than 0.5-mm change, and
maxillary clinical crown heights did not change significantly, indi-
cating favorable periodontal conditions [6]. Another article with 1-
year post-expansion reported similar stable skeletal and dental
changes [4]. In addition, the decreased buccal bone thickness and
increased palatal bone thickness experienced during expansion
tended to return to pre-treatment pattern with increase in buccal
bone thickness and decrease in palatal bone thickness during the
follow-up period. The maxillary molar inclination, which had been
buccally tipped immediately after expansion, was also returned [4].
Both reports showed good stability of the maxillary expansion by
MARPE without significant periodontal side effects. However, there
have been few longer follow-up results, especially with post-
retention data. Moreover, various retention protocols after MARPE
have been reported, pointing towards necessity for well-
established retention protocols.
5. Airway issues and MARPE
It is known that palatal expansion can widen the nasal cavity,
and thereby improve breathing (Fig. 4) [18]. Because MARPE has
been proven to expand bony maxilla more efficiently than the
conventional RPE, it is expected to have better efficiency in
widening the airway. The airway is not only related to the bony
tissue but also to the surrounding soft tissue. MARPEs effectiveness
in widening the airway and improvement in breathing function
should be evaluated with caution. Widening of the bony maxilla can
cause changes in tension, shape, and form of soft tissue in the nasal
cavity and nasopharynx, which might have influence on the adja-
cent soft tissues of the oropharynx and laryngopharynx that are
physically and functionally connected. This effect can be immediate
or delayed due to the latent period for adaptation. CBCT studies
showed an increase of the volume in the nasal cavity and naso-
pharynx after MARPE (Fig. 5) [19e22]. Interestingly, an additional
 H.-S. Baik et al. / Journal of the World Federation of Orthodontists 9 (2020) S54eS58 S57

Fig. 4. Expansion of the maxilla and the related nasal airway after miniscrew-assisted maxillary palatal expansion.

increase in nasal cavity volume was detected at 1 year after
expansion, which could be explained as a result of nasal wall
adaptation [19].
Sole anatomic and morphological investigations may not pro-
vide direct evidence of airway function. Using computational fluid
structural analysis, an increase in volume and decrease in airflow
velocity and pressure in the nasopharynx and oropharynx after
maxillary expansion with MARPE was reported in a patient having
obstructive sleep apnea [21]. Another study used a more direct
functional method with an analog manometer [22]. There was an
increase in maximum expiratory and inspiratory pressure imme-
diately and 5 months after expansion, respectively. However, more
studies with direct subjective and objective measures for airway
function are required to predict MARPE effects on patients with
breathing problems and determine and differentiate who can be
benefitted.
6. Discussion and future issues
Considering MARPE, it is likely that we are still at the first wave
of studies analysing its treatment effects. Many clinical and aca-
demic questions on treatment effects are yet to be answered.
Furthermore, some of the reported results are also contradictory.
MARPE can deliver expansion force directly to the palatal bone
through miniscrews, which are placed near the target - midpalatal
suture. These directiveness and close force application points are
considered to be the reason for more effective/extensive skeletal
changes and applicability to older patients compared to the

Fig. 5. Axial view of the nasal airway from the nostril (top) to the oropharynx (bottom) before (left, yellow) and after (right, red) maxillary expansion.
S58 H.-S. Baik et al. / Journal of the World Federation of Orthodontists 9 (2020) S54eS58
conventional RPE. The sources of major resistance to palatal
expansion are the zygomatic buttress, pterygopalatine suture,
midpalatal suture, and other peri-maxillary sutures. Based on the
published results so far, we can speculate that MARPE, in compar-
ison to the conventional RPE, would be better to open, disarticulate,
split, or bend the maxillary and peri-maxillary structures with its
improved force delivery system. In other words, MARPE is a tool
helping to exert force beyond anatomical resistances, instead of
reducing them. Corticopuncture of the midpalatal suture is a good
example of a supplemental procedure for MARPE that reduces
resistance. Predictors for successful MARPE would be how we can
assess these resistances.
The design of the MARPE and activation protocol differed across
the studies. The length, diameter, position, and number of minis-
crews placed also showed wide variation. These diversities are
thought to be the main reason for different results among studies
investigating MARPE effects. Several finite element method (FEM)
studies were performed to determine the most effective design of
MARPE along with appropriate number, design, and place of min-
iscrews [23e26]. In terms of stress distribution, a bone-borne RPE
with miniscrews placed in the palatal slope showed the lowest stress
concentrations without buccal tipping of dentition compared with
other types of RPE, including a bone-borne RPE with miniscrews
placed near the midpalatal suture, MARPE, and conventional RPE
combined with surgery [23]. Seong et al. [24] insisted on their FEM
study that MARPE is better compared with conventional RPE and
bone-borne RPE in terms of force delivery to the peri-maxillary su-
tures and stress to the buccal plate of the anchor teeth. Yoon et al.
[25] tested various situations, including the length and position of
miniscrews, position of the expander screw, and distance between
the expander screw and miniscrews. Stress distribution was wider
when four miniscrews supported MARPE in comparison to only two
miniscrews supporting it. Interestingly, their results showed no
difference in stress distribution between monocortical and bicortical
miniscrews, which contradicts the FEM study of Lee et al., which
showed that bicortical miniscrews are superior to monocortical ones
in palatal expansion [25,26]. These divergencies might have occured
due to different study settings and designs of the palatal expander.
Yoon et al. [25] used the MARPE design, whereas Lee et al. [26] used
the bone-borne design. A recent retrospective clinical study evalu-
ating monocortical and bicortical miniscrew design showed that
more skeletal expansion occurred with 4- or 2-bicortical miniscrews
compared with 4-monocortical miniscrews retained MARPE [27].
More studies are required to reach a consensus on the number,
diameter, length, and position of miniscrews and the design, acti-
vation protocol, and position of the expander.
In this article, the authors reviewed the literature, mainly
focusing on recent articles published after 2017. Most of the studies
utilized a retrospective design limiting the available scientific evi-
dence to a rather low level of knowledge is available [12]. Studies
are mostly limited to young adult (late teens-early twenties) sub-
jects. The non-MARPE control group was not adopted in most
clinical studies, and instead, before expansion data from the same
patients served as a control. Furthermore, the number of samples
was small, mostly less than 30, with a relatively short follow-up
period (mostly less than a year). Randomized clinical trials with
larger sample sizes, proper control groups, and longer follow-up
periods are needed to build a higher level of knowledge.
References
[1] Lee KJ, Park YC, Park JY, Hwang WS. Miniscrew-assisted nonsurgical palatal
expansion before orthognathic surgery for a patient with severe mandibular
prognathism. Am J Orthod Dentofacial Orthop 2010;137:830e9.
[2] Melsen B. Palatal growth studied on human autopsy material. A histologic
microradiographic study. Am J Orthod 1975;68:42e54.
[3] Melsen B, Melsen F. The postnatal development of the palatomaxillary region
studied on human autopsy material. Am J Orthod 1982;82:329e42.
[4] Lim HM, Park YC, Lee KJ, Kim KH, Choi YJ. Stability of dental, alveolar, and
skeletal changes after miniscrew-assisted rapid palatal expansion. Korean J
Orthod 2017;47:313e22.
[5] Park JJ, Park YC, Lee KJ, Cha JY, Tahk JH, Choi YJ. Skeletal and dentoal-
veolar changes after miniscrew-assisted rapid palatal expansion in young
adults: A cone-beam computed tomography study. Korean J Orthod
2017;47:77e86.
[6] 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;86:713e20.
[7] Kim KA, Oh SH, Kim BH, Kim SJ. Asymmetric nasomaxillary expansion induced
by tooth-bone-borne expander producing differential craniofacial changes.
Orthod Craniofac Res 2019;22:296e303.
[8] 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;49:360e71.
[9] Cantarella D, Dominguez-Mompell R, Moschik C, et al. Zygomaticomaxil-
lary modifications in the horizontal plane induced by micro-implant-
supported skeletal expander, analyzed with CBCT images. Prog Orthod
2018;19:41.
[10] Suzuki SS, Braga LFS, Fujii DN, Moon W, Suzuki H. Corticopuncture facilitated
microimplant-assisted rapid palatal expansion. Case Rep Dent
2018;2018:1392895.
[11] Cantarella D, Dominguez-Mompell R, Mallya SM, et al. Changes in the mid-
palatal and pterygopalatine sutures induced by micro-implant-supported
skeletal expander, analyzed with a novel 3D method based on CBCT imag-
ing. Prog Orthod 2017;18:34.
[12] Copello FM, Maranon-Vasquez GA, Brunetto DP, et al. Is the buccal alveolar
bone less affected by mini-implant assisted rapid palatal expansion than by
conventional rapid palatal expansion? A systematic review and meta-analysis.
Orthod Craniofac Res 2020;23:237e49.
[13] Song KT, Park JH, Moon W, Chae JM, Kang KH. Three-dimensional changes of
the zygomaticomaxillary complex after mini-implant assisted rapid maxillary
expansion. Am J Orthod Dentofacial Orthop 2019;156:653e62.
[14] Cantarella D, Dominguez-Mompell R, Moschik C, et al. Midfacial changes in
the coronal plane induced by microimplant-supported skeletal expander,
studied with cone-beam computed tomography images. Am J Orthod Den-
tofacial Orthop 2018;154:337e45.
[15] Lee SR, Lee JW, Chung DH, Lee SM. Short-term impact of microimplant-
assisted rapid palatal expansion on the nasal soft tissues in adults: a
three-dimensional stereophotogrammetry study. Korean J Orthod
2020;50:75e85.
[16] Abedini S, Elkenawy I, Kim E, Moon W. Three-dimensional soft tissue analysis
of the face following micro-implant-supported maxillary skeletal expansion.
Prog Orthod 2018;19:46.
[17] Baik HS. A cephalometric study of the maxillary and mandibular positional
changes by the rapid palatal expansion appliance in Angle's Class III maloc-
clusion patients. J Korean Dent Assoc 1980;18:371e8.
[18] Lee JG, Yoon JH, Chung YS, Baik HS. The change of nasal airway resistance after
rapid maxillaryexpansion. Korean J Otorhinolaryngol Head Neck Surg
1991;34:544e52.
[19] Kim SY, Park YC, Lee KJ, et al. Assessment of changes in the nasal airway after
nonsurgical miniscrew-assisted rapid maxillary expansion in young adults.
Angle Orthod 2018;88:435e41.
[20] Li Q, Tang H, Liu X, et al. Comparison of dimensions and volume of upper
airway before and after mini-implant assisted rapid maxillary expansion
[online ahead of print] Angle Orthod 2020;90:432e41.
[21] Hur JS, Kim HH, Choi JY, Suh SH, Baek SH. Investigation of the effects of
miniscrew-assisted rapid palatal expansion on airflow in the upper airway of
an adult patient with obstructive sleep apnea syndrome using computational
fluid-structure interaction analysis. Korean J Orthod 2017;47:353e64.
[22] Storto CJ, Garcez AS, Suzuki H, et al. Assessment of respiratory muscle strength
and airflow before and after microimplant-assisted rapid palatal expansion.
Angle Orthod 2019;89:713e20.
[23] Lee HK, Bayome M, Ahn CS, et al. Stress distribution and displacement by
different bone-borne palatal expanders with micro-implants: a three-
dimensional finite-element analysis. Eur J Orthod 2014;36:531e40.
[24] Seong EH, Choi SH, Kim HJ, Yu HS, Park YC, Lee KJ. Evaluation of the effects of
miniscrew incorporation in palatal expanders for young adults using finite
element analysis. Korean J Orthod 2018;48:81e9.
[25] Yoon S, Lee DY, Jung SK. Influence of changing various parameters in
miniscrew-assisted rapid palatal expansion: a three-dimensional finite
element analysis. Korean J Orthod 2019;49:150e60.
[26] 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;151:887e97.
[27] Li N, Sun W, Li Q, Dong W, Martin D, Guo J. Skeletal effects of monocortical and
bicortical mini-implant anchorage on maxillary expansion using cone-beam
computed tomography in young adults. Am J Orthod Dentofacial Orthop
2020;157:651e61.