Pierre Manneh (Abu Mana)

5th Course, group 13

COMPARISON BETWEEN SURGICALLY-ASSISTED

RAPID PALATAL EXPANSION (SARPE) AND
MINISCREW-ASSISTED RAPID PALATAL EXPANSION
(MARPE)
A systematic review
Master’s Thesis

Supervisor
D.D.S., PhD, prof., Arūnas Vasiliauskas

Kaunas, 2020
 FINAL MASTER‘S THESIS IS CONDUCTED
AT THE DEPARTMENT OF ORTHODONTICS

STATEMENT OF THESIS ORIGINALITY

I confirm that the submitted Final Master‘s Thesis (tittle) "Comparison between Surgically-assisted
rapid palatal expansion and Miniscew-assisted rapid palatal expansion".
1. Is done by myself.
2. Has not been used at another university in Lithuania or abroad.
3. I did not used any additional sources that are not listed in the Thesis, and I provide a complete list
of references.

I confirm by e-mail, and the work will be signed after the end of the quarantine and emergency situation due
to the COVID-19 pandemic in the republic of Lithuania.

(date) (autthor‘s full name) (signature)

Pierre Manneh (Abu Mana)

CONCLUSION OF FINAL MASTER‘S THESIS ACADEMIC SUPERVISOR

ON THE DEFENSE OF THE THESIS
I confirm by e-mail, and the work will be signed after the end of the quarantine and emergency situation due
to the COVID-19 pandemic in the republic of Lithuania.

(date) (author‘s full name) (signature)

Arūnas Vasiliauskas

FINAL MASTER‘S THESIS IS APPROVED AT THE DEPARTMENT

I confirm by e-mail, and the work will be signed after the end of the quarantine and emergency situation due
to the COVID-19 pandemic in the republic of Lithuania.

(date of approval) (name of the Department and full name of the Head of the Department) (signature)

Final Master‘s Thesis reviewer

I confirm by e-mail, and the work will be signed after the end of the quarantine and emergency situation due
to the COVID-19 pandemic in the republic of Lithuania.

(full name) (signature)

Evaluation of Final Master‘s Thesis Defense Board:
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to the COVID-19 pandemic in the republic of Lithuania.

(date) (full name of the secretary of Master‘s Thesis Defense Board) (signature)
 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY
FACULTY OF ODONTOLOGY
THE CLINIC OF ORTHODONTICS

COMPARISON BETWEEN SURGICALLY-ASSISTED

RAPID PALATAL EXPANSION (SARPE) AND
MINISCREW-ASSISTED RAPID PALATAL EXPANSION
(MARPE)
Master’s Thesis

The thesis was done

by student …………………………... supervisor ……………………...
(name surname, year, group) (degree, name surname)

……………………………………….. ……………………………………
(signature) (signature)

……………………… 20…. ……………………… 20….

(day/month) (day/month)

Kaunas, 2020
 EVALUATION TABLE OF THE MASTER’S THESIS
OF THE TYPE OF SYSTEMIC REVIEW OF SCIENTIFIC LITERATURE

Evaluation: ....................................................................................................................................

Reviewer: ...................................................................................................................................
(scientific degree. name and surname)
Reviewing date: ...........................................

Compliance with MT
requirements and
No. MT parts MT evaluation aspects
evaluation
Yes Partially No
Is summary informative and in compliance with the
1 0.3 0.1 0
Summary thesis content and requirements?
(0.5 point) Are keywords in compliance with the thesis
2 0.2 0.1 0
essence?
Are the novelty, relevance and significance of the
3 Introduc- 0.4 0.2 0
work justified in the introduction of the thesis?
tion, aim
Are the problem, hypothesis, aim and tasks formed
4 and tasks 0.4 0.2 0
clearly and properly?
(1 point)
5 Are the aim and tasks interrelated? 0.2 0.1 0
6 Selection Is the protocol of systemic review present? 0.6 0.3 0
criteria of Were the eligibility criteria of articles for the
7 the studies, selected protocol determined (e.g., year, language, 0.4 0.2 0
search publication condition, etc.)
methods and Are all the information sources (databases with
strategy dates of coverage, contact with study authors to
8 0.2 0.1 0
(3.4 points) identify additional studies) described and is the last
search day indicated?
Is the electronic search strategy described in such a
way that it could be repeated (year of search, the
9 last search day; keywords and their combinations; 0.4 0.1 0
number of found and selected articles according to
the combinations of keywords)?
Is the selection process of studies (screening,
eligibility, included in systemic review or, if
10 0.4 0.2 0
applicable, included in the meta-analysis)
described?
Is the data extraction method from the articles
11 (types of investigations, participants, interventions, 0.4 0.2 0
analysed factors, indexes) described?
Are all the variables (for which data were sought
12 and any assumptions and simplifications made) 0.4 0.2 0
listed and defined?
Are the methods, which were used to evaluate the
13 risk of bias of individual studies and how this 0.2 0.1 0
 information is to be used in data synthesis,
described?
Were the principal summary measures (risk ratio,
14 0.4 0.2 0
difference in means) stated?
Is the number of studies screened: included upon
15 assessment for eligibility and excluded upon giving 0.6 0.3 0
the reasons in each stage of exclusion presented?
Are the characteristics of studies presented in the
included articles, according to which the data were
16 Systemiza- 0.6 0.3 0
extracted (e.g., study size, follow-up period, type of
tion and
respondents) presented?
analysis of
Are the evaluations of beneficial or harmful
data
outcomes for each study presented? (a) simple
17 (2.2 points) 0.4 0.2 0
summary data for each intervention group; b) effect
estimates and confidence intervals)
Are the extracted and systemized data from studies
18 presented in the tables according to individual 0.6 0.3 0
tasks?
Are the main findings summarized and is their
19 0.4 0.2 0
relevance indicated?
Discussion Are the limitations of the performed systemic
20 0.4 0.2 0
(1.4 points) review discussed?
Does author present the interpretation of the
21 0.4 0.2 0
results?
Do the conclusions reflect the topic, aim and tasks
22 0.2 0.1 0
Conclusions of the Master’s thesis?
23 (0.5 points) Are the conclusions based on the analysed material? 0.2 0.1 0
24 Are the conclusions clear and laconic? 0.1 0.1 0
Is the references list formed according to the
25 0.4 0.2 0
requirements?
Are the links of the references to the text correct?
26 Are the literature sources cited correctly and 0.2 0.1 0
References precisely?
(1 point) Is the scientific level of references suitable for
27 0.2 0.1 0
Master’s thesis?
Do the cited sources not older than 10 years old
28 form at least 70% of sources, and the not older than 0.2 0.1 0
5 years – at least 40%?
Additional sections, which may increase the collected number of points
Do the presented annexes help to understand the
29 Annexes +0.2 +0.1 0
analysed topic?
Practical
Are the practical recommendations suggested and
30 recommen- +0.4 +0.2 0
are they related to the received results?
dations
Were additional methods of data analysis and their
31 results used and described (sensitivity analyses, +1 +0.5 0
meta-regression)?
 Was meta-analysis applied? Are the selected
32 statistical methods indicated? Are the results of +2 +1 0
each meta-analysis presented?
General requirements, non-compliance with which reduce the number of points
33 Is the thesis volume sufficient (excluding 15-20 pages <15 pages
annexes)? (-2 points) (-5 points)
34 Is the thesis volume increased -2 points -1 point
artificially?
35 Does the thesis structure satisfy the -1 point -2 points
requirements of Master’s thesis?
36 Is the thesis written in correct language, -0.5 point -1 points
scientifically, logically and laconically?
37 Are there any grammatical, style or -2 points -1 points
computer literacy-related mistakes?
38 Is text consistent, integral, and are the -0.2 point -0.5 points
volumes of its structural parts balanced?
General >20%
39 Amount of plagiarism in the thesis.
require- (not evaluated)
ments Is the content (names of sections and sub-
40 sections and enumeration of pages) in -0.2 point -0.5 points
compliance with the thesis structure and
aims?
Are the names of the thesis parts in
41 compliance with the text? Are the titles of -0.2 point -0.5 points
sections and sub-sections distinguished
logically and correctly?
42 Are there explanations of the key terms -0.2 point -0.5 points
and abbreviations (if needed)?
Is the quality of the thesis typography
43 (quality of printing, visual aids, binding) -0.2 point -0.5 points
good?
*In total (maximum 10 points):

*Remark: the amount of collected points may exceed 10 points.

Reviewer’s comments: ___________________________________________________________

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Reviewer’s name and surname Reviewer’s signature

 TABLE OF CONTENTS

1. SUMMARY ................................................................................................................................. 9
2. INTRODUCTION ...................................................................................................................... 10
3. SEARCH METHODS AND STRATEGY ................................................................................ 12
4. SYSTEMIZATION AND ANALYSIS OF DATA ................................................................... 17
5. COMAPRISON BETWEEN MARPE AND SARPE .............................................................. 18
6. DISCUSSION ........................................................................................................................... 20
7. CONCLUSIONS ........................................................................................................................ 23
8. PRACTICAL RECOMMENDATIONS .................................................................................... 24
9. REFERENCES ........................................................................................................................... 25
10. ANNEX ...................................................................................................................................... 28
 1. SUMMARY

Title:
Comparison between surgically-assisted rapid palatal expansion (SARPE) and miniscrew-assisted
rapid palatal expansion (MARPE).

Introduction:
This systematic review was aimed to compare the dental and skeletal changes between miniscrew-
assisted rapid palatal expansion (MARPE) and surgically assisted rapid palatal expansion (SARPE).

Materials and Methods:

Publications relevant to our aim were identified by conducting a search in databases, such as
PubMed/Medline, Cochrane and Ebsco Publishing. Data were extracted from the full articles after
screening of the abstracts and titles. Articles included studies on humans and published in English
language.

Results:
The research yielded a total of 235 results through preliminary search. After application of inclusion
and exclusion criteria a total of 6 articles were chosen to be eligible for this systematic review.
A total of 155 patients were enlisted in this systematic review.

Conclusion:
Miniscrew-assisted rapid palatal expansion (MARPE) and surgically assisted rapid palatal expansion
(SARPE) were found to be effective procedures to correct a transverse maxillary deficiency. In
addition, the transverse width measurements did not differ between the two modalities of procedure.

Keywords:
Surgically assisted rapid palatal expansion, mini-screws, rapid palatal expansion, cone-beam
computed tomography.

9
 2. INTRODUCTION

Transverse maxillary discrepancy is a common malocclusion among adolescents and adults, which is
usually presented with a bilateral or unilateral posterior crossbite, narrow nasal cavity, and crowding
[1,2]. Expansion of the maxilla is a treatment method that was described firstly in 1860 by Angell in
a case report, which opened the midpalatal suture laterally by a palatal expansion appliance [3]. One
hundred years later, Andrew Haas introduced the Haas expander to the United States and was the first
to report on the increase of arch perimeter and an increase in nasal width [4].

Rapid maxillary expansion (RME) has become a routine procedure in orthodontic treatments and
many studies have shown its efficiency in expanding the maxilla [5]. This technique was implemented
by the clinicians in patients who have growth potential. However, the effect of using rapid maxillary
expansion was less predictable for patients that are older than 15-year-old because this device was
tooth-borne expander [6]. An expansion that has performed after the peak of pubertal growth spurt
will lead to dental changes more than skeletal changes with side effects such as buccal dental tipping.
In addition, the limit of skeletal effect was around 4 mm since the transverse expansion of the maxilla
would be inevitably compensated by dental tipping [7].

Therefore, a surgical approach is often required to expand a constricted maxilla after skeletal
maturity, due the fusion of midpalatal and maxillary sutures. The segmental Le Fort I osteotomy is a
surgical technique that is done to correct constricted maxilla up to 6-7 mm in adults. However,
expansion of maxilla with segmental Le Fort I osteotomy is usually associated with postsurgical
relapse and instability [8].

In 1938, the concept of Surgically Assisted Rapid Palatal Expansion (SARPE) was introduced by
Brown [9], and since then SARPE procedure has gradually become the main treatment modality for
adult patients with maxillary transverse deficiency [10]. The primary goal is to get skeletal expansion
more than dental expansion and to minimize dental tipping by separating the midpalatal and laterally
maxillary sutures. In this technique, the expansion procedure is based on distraction osteogenesis of
palatal bones after surgical operation [11].

The appliance that is used for expansion after SARPE has basic importance such as assisting,
obtaining and maintaining the required expansion [12]. Tooth-borne expanders are the most
commonly used treatment choice after SARPE in adult patients, but they often cause root resorption,
dental tipping, periodontal damage and alveolar deformation.
10
Therefore, many adults were not confident in choosing SARPE due to complications, risks, invasive
procedure and cost of the surgical procedure [13].

Due to the shortcomings of those procedures, a new treatment modality was needed. In 2010 Lin et
al. introduced the Miniscrew-Assisted Rapid Palatal Expansion (MARPE) appliances for adolescent
patients with constricted maxilla. The role of this appliance is to optimize the potential skeletal
expansion and to solve undesirable dentoalveolar effects in patients with advanced stages of skeletal
maturation. Lin et al. compared between tooth-borne and bone-borne maxillary expanders and
concluded that bone-borne expanders can produce bigger orthopedic effects in late adolescents and
adult patients [14,15].

The purpose of the preceding review was to provide information about a new technique for transverse
maxillary deficiency and to compare it to the previous technique, which is more invasive and demands
surgical approach. The comparison of both techniques was based on the same landmarks and the same
investigation tool, cone-beam computed tomography.
The aim of the present systematic review was to compare skeletal and dental changes between
surgically assisted rapid palatal expansion (SARPE) and miniscrew assisted rapid palatal expansion
(MARPE), using cone-beam computed tomography.

Tasks:
- To compare the intermolar width after expansion treatment with MARPE and SARPE.
- To compare the interpremolar width after expansion treatment with MARPE and SARPE.
- To compare the nasal floor width after expansion treatment with MARPE and SARPE.

Hypothesis:
The hypothesis of this systematic review is that the dental and skeletal measurements obtained after
MARPE do not differ significantly from SARPE.

11
 3. SEARCH METHODS AND STRATEGY

Protocol
The protocol for this systematic review was conducted following the PRISMA (Preferred Reporting
Items for Systematic Reviews and Meta-analyses) statement [16]. Approval was acquired by the local
bioethics committee (No. BEC-OF(U)-123).

Formulating the Focus Question:

The focus question was developed by using the population, intervention, comparison, and the
outcome framework, which is presented in Table 1.

Table 1. PICO table

Component Description
Non-syndromic patients (age ≥15) with a transverse maxillary
Population (P) deficiency.

Intervention (I) Rapid palatal expansion for late adolescents and adults.
Mini-screw assisted rapid palatal expansion – MARPE versus
Comparison (C)
surgically assisted rapid palatal expansion - SARPE.

Transverse maxillary skeletal and dentoalveolar expansion changes

Outcome (O)
after treatment with MARPE and SARPE technique.

Is there any difference in the transverse maxillary dental or skeletal

Focus Question
expansion between MARPE and SARPE technique?

Types of Publications
The review included studies on humans published in the English language.

Types of Studies
The systematic review included all human randomized controlled clinical trials, retrospective studies
and prospective cohort studies published between 2012 and 2020, which reported on skeletal and
dentoalveolar changes after MARPE appliances treatment and comparison between tooth-borne and
bone-borne following SARPE treatment.

12
Information Sources
The information sources were PubMed/Medline, Cochrane, and Ebsco publishing.

Literature Search and Screening

The electronic PubMed/Medline, Cochrane, and Ebsco Publishing databases were searched. In
addition, the bibliography of all relevant textbooks and articles were manually searched to find
additional relevant data. The articles were selected based on the inclusion and exclusion criteria.
Different keyword combinations were used to find relevant data and Table 2 shows a summary of the
results.

Table 2. Summary of Keyword Combination

Search
Keyword combination
dates
First date Block 1
of search “Palatal expansion” OR
15/09/2019 “maxillary expansion”,
“surgery”, “cone-beam
computed tomograpyh”.
“Tooth-borne”, “Bone-bone”,
“rapid palatal expansion”,
“surgery”.
“Surgically assisted rapid
palatal expansion” OR
“Surgical assisted rapid
maxillary expansion”, “ cone-
beam computed tomography”.
Last date “Surgically assisted rapid
of search palatal expansion” OR
20/03/2020 “Surgical assisted rapid
maxillary expansion”, “ cone-
beam computed tomography ”.
Results
Block 2 Block 1 Block 2
“Non-surgical”, “rapid palatal 203 210
expansion”, “cone-beam
computed tomography”,
34 43
“miniscrew” OR “mini
implant”, “palatal expansion”
OR “maxillary expansion”,
“CBCT”.
190 43
“Miniscrew-assisted rapid
palatal expansion” OR “mini
implant-assisted rapid palatal
expansion”, “ cone-beam
computed tomography”.
“Miniscrew-assisted rapid
palatal expansion” OR “mini
implant-assisted rapid palatal 196 49
expansion”, “ cone-beam
computed tomography”.

Selection Criteria
The inclusion criteria were the following:
-Publications written in the English language.
-Studies performed on humans only.
-Studies done on young adults and/or adult patients, mean age greater than or equal to 15.
-Studies published from January 1st 2010 to March 2020.
-Randomized clinical trials, controlled prospective clinical studies and retrospective clinical studies.

13
Exclusion criteria were the following:
-Publications older than 10 years.
-Publications in languages other than English.
-Case reports, systematic reviews and Meta-Analyses.
-Studies performed on animals.
-Studies using evaluation tool other than cone-beam computed tomography

Literature Search Strategy

To identify the appropriate studies, a detailed electronic search was carried out according to PRISMA
guidelines [16] within PubMed/Medline, Cochrane and Ebsco Publishing databases using different
combinations of keywords. The search was performed in two different blocks in order to find all the
relevant articles and studies (Table 2). The following keywords were: “surgically assisted rapid
palatal expansion”, “rapid palatal expansion”, “mini-screws”, “cone-beam computed tomography”.
The search details for the first block were as followed: ("surgically"[All Fields]) AND assisted [All
Fields] AND rapid [All Fields] AND ("palate"[MeSH Terms] OR "palate" [All Fields] OR
"palatal"[All Fields]) AND expansion[All Fields]) AND ("cone-beam computed tomography"[MeSH
Terms] OR ("cone-beam computed tomography") [All Fields].
The search details for the second block are as followed: (miniscrew[All Fields] AND assisted[All
Fields] AND rapid[All Fields] AND ("palate"[MeSH Terms] OR "palate"[All Fields]) AND
expansion[All Fields]) AND ("cone-beam computed tomography"[MeSH Terms] OR "cone-beam
computed tomography"[All Fields].

Selection of Studies
The resulting articles were independently subjected to clarify inclusion and exclusion criteria. Firstly,
titles and abstracts were obtained in the first step of the process to identify full articles that were
considered adequate for inclusion in this review.
The database search showed 80 articles in PubMed, 34 articles in Cochrane and 131 articles were
identified in Ebsco. A synopsis of the article’s selection process is described in Figure 1, by using the
PRISMA flow chart. After removal of 152 duplicate articles, 93 articles remained. During the
preliminary step of screening process, 67 articles were excluded because they were irrelevant based
on the exclusion criteria. During the next step of the screening process, 10 more articles were removed
because they did not meet the inclusion criteria.

14
 •PubMed/Medline, Ebsco,
Additional records identified
Cochrane Library database advanced search
through other sources
•Search keywords: ‘’surgically assisted
(N=0)
Identification rapid maxillary expansion“, “Mini-screws”,
“rapid palatal expansion”,”cone-beam
computed tomography”
•Language: English
(N=245)

Removel of
Records after duplicates removed Filtered duplication
(N=93) (N=152)

(n = 400 )

Records screened
(N=93)
Screening

Exclusion criteria
-Not relevant title and
abstract records excluded
Filtered (n =67)
-Review (n=7)
-Case report (n=3)

Full-text articles assessed for eligibility

Eligibility

(N=16)

Full-text articles
reviewed and excluded:
Filtered - not relevant content
(N=10)

Studies included in qualitative synthesis

(N=6)
Included

Figure 1. PRISMA flow diagram

15
Assessment of Risk of Bias
Once the articles of this review were identified and reviewed, Quality Assessment Tool for
Quantitative Studies (QATQS) was used to assess the quality of the studies [17]. QATQS consists of
six criteria and each of them can be rated as strong, moderate, or weak according to a specific
definition in the QATQS dictionary (Annex 1). Studies with no weak rating and four strong ratings
were classified as “strong;” whereas studies with more than one weak rating were classified as
“weak;.” Studies with only one weak rating or less than four strong ratings were classified as
“moderate.”
The results are summarized in Table 3. Systematization of data presented in Table 4.

Table 3. Risk of bias

Data Withdrawals
Selection Study
References Confounders Blinding collection and Score
Bias design
method dropouts

Nada et al.
2012 [18] Moderate Moderate Weak Moderate Strong Moderate Weak

Kayalar et
al. 2015 Moderate Strong Moderate Moderate Strong Moderate Moderate
[19]
Seeberger
et al. 2015 Weak Moderate Moderate Weak Strong Moderate Weak
[20]
Park et al.
2016 [21] Moderate Moderate Moderate Weak Moderate Moderate Moderate

Lim et al.
2017 [22] Weak Moderate Moderate Moderate Moderate Moderate Moderate

Yi et al.
2020 [23] Moderate Moderate Weak Moderate Moderate weak weak

16
 4. SYSTEMIZATION AND ANALYSIS OF DATA
Table 4. Characteristics of the qualified studies in the systematic review
Researcher Study design Sample Study group Type of expander Gender Age group Activation protocol Surgical Observation period Dental Investigation
procedure
size (mean±SD) landmark Method
Nada et al. Prospective 45 I: Tooth-borne Hyrax Device I: 28 (F) I: 24.5±9 1 mm/day Le Fort I T1 before -Mesiobuccal Coronal
osteotomy treatment cusp of the CBCT images
2012 [18] study SARPE
with PD T2 after first molars
-Buccal cusp
orthodontic
TPD of the first
II: Bone-borne II:17 (M) II: 29.4±10 treatment (mean - premolar
SARPE 22.6 months later)

Kayalar et al. Randomized 20 I: Tooth-borne Hyrax Device I: 10 I:19.2±3.64 Activation until a Le Fort I T0 - before -Mesiobuccal Coronal
diastema osteotomy treatment cusp tips of CBCT images
2015 [19] controlled SARPE (3 M; 7 F) of 1 mm could with PD T1 - after active the first molar
clinical trial be seen -buccal cusp
during surgery and expansion
Hybrid tip of the first
II: Hybrid II: 10 II:19.3±5.01 0.25 mm twice a day T2 - after 6 m premolar
device (6 M; 4 F) for 14 days retention
SARPE
Seeberger et Retrospective 33 I: Bone-borne Titamed Uni- I: 19 I: 22 0.5 mm/day Subtotal Le Fort I T1 1 month -Mesiobuccal Coronal CBCT
smile distractor osteotomy before treatment cusp tips of images
al. 2015 [20] study SARPE (8 M; 11F)
T2 3 months after the first molar
-buccal cusp
treatment
Hyrax device tip of the first
II: Tooth-borne II: 14 II: 30 premolar
SARPE (6 M; 8 F)

Retrospective 14 MARPE Hyrax type RPE 9M 20.1±2.4 Once a day / T1 before -Mesiobuccal Coronal CBCT
Park et al. device. (0.2mm/turn) until cups tips of the images
study 5F treatment
2016 [21] the required T2 after
first molar.
expansion had been -Buccal cups
achieved
expansion (mean of first
duration 38 days) premolar.

Retrospective 24 MARPE Hyrax 8M 21.55±3.14 Once a day / T0 before -Mesiobuccal Coronal CBCT
Lim et al. (0.2mm/turn) until cusp of first images
study 16 F treatment
2017 [22] the required T1 immediately
molars
expansion had been -buccal cups of
achieved
after treatment premolars
T2 1 year after
treatment
Yi et al. 2020 Retrospective 19 MARPE Palatal bracket 15 F 19.91±4.39 Twice a day / T1 before -Buccal cusp CBCT images
implant anchorage (0.25mm/turn) for treatmet of first molar
[23] study 4M
arch expander 14 days T2 3 months after and first
premolar.
treatment
SARPE – surgical assisted rapid palatal expansion, MARPE- mini-screw assisted rapid palatal expansion, TPD – transpalatal distractor M – men, F- female, PD - pterygomaxillary disjunction, CBCT-
cone-beam computed tomography.

17
 5. COMPARISON BETWEEN MARPE AND SARPE

The following studies show the measurements of the width between first premolars and the width
between first molars and nasal floor after treatment with MARPE and tooth-borne and bone-borne
following SARPE using cone-beam computed tomography as an investigation method (Table 5).

Table 5. Comparison of expansion between MARPE and SARPE after treatment (mm)

SARPE
MARPE
Tooth-borne Bone-borne
Study
Sample
size IPMW IMW NF IPMW IMW NF IPMW IMW NF

Nada et al.
7.03 5.64 6.95
2012 45 ---- ---- ---- NR 6.77±3.5 NR
±3.5 ±2.9 ±3.2
Kayalar et 6.13 6.13 4.74 6.13±
al. 2015 20 ---- ---- ---- NR NR
±1.47 ±1.47 ±0.79 1.62
Seeberger 5.55 5.45 0.65 3.40 1.50
4.60 (3.4
et al. 2015 33 ---- ---- ---- (5.23 (4.95 (2.73 (2.40 (3.4
IQR)
IQR) IQR) IQR) IQR) IQR)
Park et al. 5.5
2016 14 5.4 ± 1.7 NR ---- ---- ---- ---- ---- ----
±1.4
Lim et al. 5.96 2.20
2017 24 5.63 ± 1.90 ---- ---- ---- ---- ---- ----
±1.20 ± 1.01
Yi et al. 3.14 1.77
2020 19 3.92±2.36 ---- ---- ---- ---- ---- ----
±2.27 ±1.48
IPMW -interpremolar width, IMW- intermolar width, NF- nasal floor, IQR - interquartile range, NR- not
reported.
*Data are presented as mean ± standard deviation.

In this review all included studies have identical dental landmarks in order to have as much possible
accurate results between two modalities of expansion of the maxilla. Interpremolar (IPMW) and
intermolar (IMW) width were defined as the distance between the right and left mesiobuccal cusp tip
of first premolars and first molars. In the study performed by Nada et al. [18] in 2012, forty -five
consecutive patients were included in this study and the mean age at the time of surgery procedure
was 29.4±10 years. All patients had undergone the same surgical procedure, Le Fort I with midline
osteotomy and pterygo-maxillary disjunction. The mean expansion of patients who had tooth-born
appliance at first premolars was 7.03±3.5mm and at first molars was 5.64±2.9mm. However, patients
who had bone-borne appliance the mean expansion at the first premolar was 6.95±3.2mm and at the
first molars was 6.77±3.5mm. In the research conducted by Kayaler et al. [19] in 2016, there was
significantly less expansion in the anterior part in bone-borne appliance during the active expansion
period compared to tooth-borne appliance. The width of the first premolar in bone-borne was

18
4.74±0.79 mm compare to tooth-borne which was 6.13 ±1.47mm (p=0.019). However, the posterior
part at the first molars was similar in both groups (p>00.5). In the study of Seeberger et al. [20] in
published 2015 the chosen statistical methodology was different as they used robust measures, such
as the median for location and the interquartile range (IQR). Therefore, in this study the median
transverse dental expansion in the first premolar didn’t change significantly between tooth-borne and
bone-borne. In the tooth-borne group the distance was 5.55mm (IQR 5.23) and in the bone-borne was
4.6mm (IQR 3.4). However, there was a significant difference between the two groups at the level of
the crowns between the molars - 5.45 mm (IQR 4.95) in the tooth-borne group and 3.40mm (IQR
2.40) in the bone-bone device group (p ≤0.02).

In the study of Park et al [21] published in 2016, fourteen patients (mean age, 20.1±2.4 years) with
maxillary constriction had undergone maxillary expansion by MARPE. The width between the left
and right first premolars and first molars had increased by 5.5mm and 5.4mm, respectively, after
MARPE (p <0.001). Lim et al [22], in their study included 24 patients (mean age, 21.6±3.1 years)
that were treated with MARPE. The measurements of the distance between left and right first
premolars and first molars significantly increased immediately after treatment. The width increase
between first premolars was 5.96mm and the width between molars increased by 5.63mm (p < 0.001).
The outcome measure of nasal floor that was measured after treatment was 2.20 ±1.01mm. In a
different study done by Yi et al [23], 19 patients aged 15-29 years old with maxillary transverse
deficiency were treated with MARPE. The distance of all parameters compared with that before the
treatment has statistically significantly increased between the first premolars and first molars by
3.14mm and 3.92mm, respectively. In addition, nasal floor was measured at the level of premolars
and molars. The width of nasal floor increased between first premolars and was 1.97±2.88mm and
the nasal floor between first molars was 1.77±1.48mm wider respectively.

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 6. DISCUSSION

The preceding review examined transverse dental and skeletal changes after expansion in adolescents
and adults using cone-beam computed tomography as an investigation tool. The purpose of the study
was to evaluate quantitative measurements that can help in the therapy selection for the orthodontist
and the oral surgeon and to compare the outcome measures of skeletal and dental expansion between
MARPE and tooth-borne and bone-borne following SARPE.

A total of six studies [18-23] were included in the qualitative review. They satisfied the inclusion
criteria reporting changes solely due to the implementation of MARPE and SARPE procedures. The
analysis of risk of bias indicated that three of the studies have moderate bias and three of them are
weak. The introduction of bone anchorage in the field of orthodontics via orthodontic miniscrews has
made great revolution. Therefore, in recent years many reports were published on orthodontic skeletal
anchorage systems incorporating miniscrews and orthodontic implants, showing or proving their
increasing importance and influence [24].

Understanding the variability of each individual in the fusion of midpalatal suture is essential for
choosing the appropriate treatment for adolescents and adults. The midpalatal sututre has been
described as an end-to-end type of suture with morphology that changes during growth. The
beginning and progress of fusion of the midpalatal suture differs greatly with sex and age. Persson
and Thilander have observed that the fusion of the midpalatal suture occurs in subjects ranging from
15 to 19 years old. However, patients at ages 27, 32, 54 and even 71 years have been showed to have
no signs of fusion of this suture. These findings pointed out that chronological age especially in young
adults does not have a large impact on the variability in the developmental stages of fusion in the
midpalatal suture [25]. In this systematic review chronological mean age of all included studies of
patients was identical and the age of patients was between 15 to 39 years old.

All the included studies [18-23] showed that MARPE and SARPE are effective treatment strategies
in obtaining a significant expansion of the maxillary transverse deficiency. According the findings in
this review between these two modalities of treatment the mean transverse width after expansion was
similar. Although, the outcome measurements of the width between premolar and molar with MARPE
were lower but it shows that with this kind of treatment a transverse expansion was achieved. SARPE
with tooth-borne and bone-borne appliance is a well-established surgical procedure used to correct
severe maxillary transversal deficiency. However, there is no strict evidence-based treatment
guidelines in the literature regarding the surgical procedure [26]. Concerning the surgical procedure

20
taken into consideration, this review included articles that used Le Fort I osteotomy with PD
(pterygomaxillary disjunction). According to some authors, a combination of the procedures Le Fort
I with PD results in less stress and displacement in the maxilla [27], while others prefer to perform
separation of PD due to the risk of injuring the pterygoid plexus [28].

In the study conducted by Park et al. [21] the amount of transverse width at the level of cusps was
increased and expansion was similar between the anterior and posterior regions after treatment with
MARPE. Parallel expansion can be caused by distribution of resistance from the maxilla. In the same
age groups that were treated with SARPE parallel expansion of the maxilla was found due to release
of the pterygoid plates. The amount of expansion in the anterior region was greater than the posterior
when only the pterygoid plates were not released. In addition, in coronal plane maxillary expansion
after MARPE followed a pyramidal pattern, similar to the pattern reported with SARPE.

Lim et al. [22] examined transverse changes in various aspects of anatomical structures in two
different period of time after treatment with MARPE and found that immediately after treatment
expansion included 39.1% skeletal at the nasal floor, 7.1% alveolar and 53% dental expansion. While
CBCT scans that were taken one year later showed 43.2% skeletal, 15% alveolar, and 41.8% dental
expansion. These percentages differed due to greater tendency of relapsing of dental parameters more
than the alveolar and skeletal measurements. The expansion percentages were different among those
reported after treatment with SARPE in a study done by Asscherickx et al. (46.3% skeletal, 33.3%
alveolar, 20.4% dental expansion) [29]. However, the proportion of skeletal expansion (39.1%)
immediately after the treatment was comparable to results after SARPE (21.5-46.3%) in other two
studies [30,31]. Yi et al. [23] reported that the greater the amount of bone expansion, the better the
bone effect of arch expansion. In his study, similar results of bone expansion were found after
treatment with MARPE compared to studies of Park et al. and Lim et al. [21,22].

In a study carried out by Kayaler [19], he reported that both devices, tooth-borne and bone-borne
have been used successfully for SARPE. However, each of them has advantages and disadvantages.
The tooth-borne expander transmits the forces of the expansion on the anchored teeth and this may
cause periodontal problems, buccal tipping of the anchoring teeth, root resorption, tooth extrusion
and relapse. In bone-borne device the force is directed to the palate, and compared to MARPE, it
produces parallel expansion with no reported severe complications after expansion. The most
common complication is inflammation and hyperplasia of the mucosa around the mini-screw [32].

21
There are several limitations of this systematic review that should be mentioned. Firstly, larger sample
size of patients would be helpful to improve the significance of the study. Secondly, due to criteria of
inclusion and exclusion regarding the dental landmarks and investigation tool that was used, many
studies were excluded and this could negatively affect the quality of the review and can limit the
number of potential parameters of comparison between the aforementioned procedures. In addition,
the high level of heterogeneity among methodology in MARPE and SARPE limited the number of
included studies. Another limitation of this review was the lack of randomized clinical trials, as most
of the studies were retrospective studies. That, inevitably can lead to insufficient data for comparison
and bias will appear.

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 7. CONCLUSIONS
The intermolar and interpremolar width increase after treatment with miniscrew-assisted rapid palatal
expansion was lower compared to the width of surgically assisted rapid palatal expansion.
Miniscrew-assisted rapid palatal expansion and surgically assisted rapid palatal expansion were found
to be an effective procedure to expand the nasal floor and correct a transverse maxillary deficiency.

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 8. PRACTICAL RECOMMENDATIONS
According to this systematic review, MARPE and SARPE are effective modalities for correcting
transverse maxillary deficiency. However, many adolescents and adult patients are discouraged from
choosing SARPE as a treatment due to the risks, complications, and the cost of surgical procedures.
It is recommended to adolescents and adults to consider MARPE as a treatment choice for narrow
maxilla due to its lesser risk of complications and less invasive compared to SARPE after individual
evaluation of the developmental stages of fusion in the midpalatal suture.

24
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15. Nojima LI, Nojima, Matilde da Cunha Gonçalves, Cunha ACd, Guss NO, Sant'Anna EF, et
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mini-implant-supported maxillary expansion appliance with two conventional expansion
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27. De Assis D, Xavier T, Noritomi P, Gonçales E. Finite element analysis of bone stress after
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28. Kanazawa T, Kuroyanagi N, Miyachi H, Ochiai S, Kamiya N, Nagao T et al. Factors
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 10. ANNEX

QUALITY ASSESSMENT TOOL FOR QUANTITATIVE STUDIES BY EPHPP (Effective

public health practice project)

COMPONENT RATINGS:
A) SELECTION BIAS
(Q1) Are the individuals selected to participate in the study likely to be representative of the
target population?
(Q2) What percentage of selected individuals agreed to participate?
B) STUDY DESIGN
In this section, raters assess the likelihood of bias due to the allocation process in an
experimental study. For observational studies, raters assess the extent that assessments of
exposure and outcome are likely to be independent. Generally, the type of design is a good
indicator of the extent of bias. In stronger designs, an equivalent control group is present and
the allocation process is such that the investigators are unable to predict the sequence.
C) CONFOUNDERS
(Q1) Were there important differences between groups prior to the intervention?
The following are examples of confounders: 1 Race 2 Sex 3 Marital status/family 4 Age 5
SES (income or class) 6 Education 7 Health status 8 Pre-intervention score on outcome
measure
(Q2) If yes, indicate the percentage of relevant confounders that were controlled (either in
the design (e.g. stratification, matching) or analysis)?
D) BLINDING
(Q1) Was (were) the outcome assessor(s) aware of the intervention or exposure status of
participants?
(Q2) Were the study participants aware of the research question?
E) DATA COLLECTION METHODS
(Q1) Were data collection tools shown to be valid?
(Q2) Were data collection tools shown to be reliable?
F) WITHDRAWALS AND DROP-OUTS
(Q1) Were withdrawals and drop-outs reported in terms of numbers and/or reasons per
group?
(Q2) Indicate the percentage of participants completing the study. (If the percentage differs
by groups, record the lowest).

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