ORIGINAL ARTICLE

Microimplant assisted rapid palatal

expansion vs surgically assisted rapid
palatal expansion for maxillary transverse
discrepancy treatment
€ ller Ledra,a Wilson Humio Murata,b Selly Sayuri Suzuki,b
Cibele Braga de Oliveira,a Priscila Ayub,a Ingrid Mu
Dirceu Barnabe  Ravelli,c and Ary Santos-Pintoa
Araraquara and Campinas, S~ao Paulo, Brazil

Introduction: This study compared the skeletal and dental changes of microimplant assisted rapid palatal
expansion (MARPE) with those produced by surgically assisted rapid maxillary expansion (SARPE) in postpeak
adolescents and adults. Methods: The sample comprised 17 patients (mean age, 26 6 11 years) selected for
the MARPE group and 15 (mean age, 28.5 6 10.5 years) selected for the SARPE group. Cone-beam computed
tomography scans taken just before and after the expansion were used to assess dental and skeletal changes
and compare the changes between the groups. Results: MARPE showed greater transversal skeletal changes
in the midface and posterior and anterior maxillary base measurements. The transverse displacement of the
alveolar process was greater but not significant for the SARPE group than the MARPE group. Regarding dental
effects, the root distance measurements did not differ between the groups, but SARPE produced a significantly
greater increase in intermolar and interpremolar distance and a greater buccal inclination of the alveolar process
and supporting teeth than MARPE. Conclusions: The MARPE technique showed an increase in skeletal trans-
verse maxillary expansion at the midface and basal bone compared with SARPE, especially at the posterior
palatal region; however, no difference was found in the expansion of the alveolar process between the 2
methods. MARPE presented a more parallel expansion in both a coronal and axial view, whereas SARPE led
to a V-shaped opening. The greater buccal inclination of the alveolar process and supporting teeth was observed
in the SARPE group. (Am J Orthod Dentofacial Orthop 2021;159:733-42)

T
reatment of transverse maxillary constriction us- growth.1 RPE prognosis is related to the level of maxil-
ing rapid palatal expansion (RPE) is most indicated lary suture interdigitation, and its effect is inversely
in mixed dentition until adolescence during related to the success of the expansion; that is, the
greater the interdigitation and more numerous the syn-
ostoses presented at the sutures, the lower the chances
a
Department of Orthodontics, Araraquara School of Dentistry, S~ao Paulo State of splitting the maxilla without surgical intervention,
University, School of Dentistry, Araraquara, S~ao Paulo, Brazil.
b known as surgically assisted rapid palatal expansion
Department of Orthodontics, S~ao Leopoldo Mandic Institute and Research Cen-
ter, Campinas, S~ao Paulo, Brazil. (SARPE).2,3
c
Department of Pediatric Dentistry, Area of Orthodontics, Araraquara School of In young adults and postpeak growth adolescents
Dentistry, S~ao Paulo State University, School of Dentistry, Araraquara, S~ao Paulo,
presenting skeletal maturity, the results of nonsurgical
Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of RPE may vary considerably.1 One study showed high
Potential Conflicts of Interest, and none were reported. success in young adults achieving a moderate expan-
This study was supported by the Coordenaç~ao de Aperfeiçoamento de Pessoal de
sion,4 whereas others found that age limited the RPE
Nıvel Superior (CAPES), Brazil, Finance Code 001.
This clinical study was previously approved by the Research Ethics Committee of success rate in females aged up to 18 years and males
the Faculty of Dentistry of Araraquara of S~ao Paulo State University (CCAAE Nos. aged up to 21 years.5 In patients aged more than
60393416.7.0000.5416 and 14484713.1.0000.5416).
18 years, the skeletal effects are insignificant, exhibiting
Address correspondence to: Cibele Braga de Oliveira, Department of Pediatric
Dentistry, S~ao Paulo State University, Av. Humaita 1680, Araraquara, S~ao Paulo more dentoalveolar expansion of the maxillary arch.6
14801-385, Brazil; e-mail, cibeleodonto@yahoo.com.br. Complications have been reported in the literature as
Submitted, August 2019; revised, February 2020; accepted, March 2020.
a consequence of conventional tooth-borne RPE de-
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved. vices, including pain and swelling during expansion,4
https://doi.org/10.1016/j.ajodo.2020.03.024

733
734
buccal root resorption of the supporting teeth,7 buccal
cortical and bone resorption,8 and bone dehiscence.9
Other authors10 reported patients with ischemia and ne-
crosis in the palate mucosa when maxillary sutures do
not respond to orthopedic forces applied through a
tooth-supported expander.
The reason for the conventional RPE failures may be
due to greater rigidity in craniofacial structures in skel-
etally mature patients.11 Therefore, SARPE is indicated
to treat transverse maxillary deficiency in adult patients.
Unfortunately, this treatment is often rejected because it
is an invasive surgical procedure, with risks and high
costs for the patient.12
Miniscrews were recently developed for use as
anchorage supporting orthopedic forces.13,14 A micro-
implant assisted rapid palatal expansion (MARPE) tech-
nique has been advocated to optimize force distribution
to the maxillary basal bone and circummaxillary struc-
tures, enhancing skeletal effects and minimizing dental
inclination9,15,16; therefore, preserving periodontal
health.17,18 A recent clinical study showed that out of
69 patients treated using MARPE, 9 had failed to split
midpalatal sutures (an 86.96% success rate) in young
adults (mean age, 20.9 6 2.9 years).19 Thus, because
of this therapy’s high success rate, it may be recommen-
ded as an alternative to surgical expansion.
This study compared the skeletal and dental changes
of MARPE with those produced by SARPE in patients
with bone maturity. We believe that this information
will help clarify the transversal changes achieved in
both treatment modalities to better guide orthodontists
to decide which method provides the most benefit to in-
dividual patients.
MATERIAL AND METHODS
This clinical study was previously approved by the
Research Ethics Committee of the Faculty of
Dentistry of Araraquara of S~ao Paulo State University
(CCAAE Nos. 60393416.7.0000.5416 and 144847
13.1.0000.5416).
The overall sample included 2 parallel controlled
groups of patients treated for transverse maxillary
deficiency using MARPE or SARPE. The MARPE sam-
ple consisted of 17 postpubertal adolescent and adults
(4 men and 13 women) with a mean age of 22.9 years
(minimum, 15; maximum, 37) treated between 2016
and 2019 at the Dental Center of Studies and Research
(COESP), Jo~ao Pessoa, Paraıba, Brazil and S~ao Paulo
State University (UNESP), Araraquara, S~ao Paulo,
Brazil. The SARPE group corresponded to a sample
obtained from the archives of the Residency Program
in Oral and Maxillofacial Surgery and Traumatology
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de Oliveira et al
Table I. Sample characteristics, descriptive statistics,
and comparative Student t test for the initial trans-
versal discrepancy between the MARPE and SARPE
groups
Group n Mean SD P (t test)
MARPE 17 6.00 2.34 0.185*
SARPE 15 7.26 2.93
Note. Transversal discrepancy is the distance between palatal cusps
of maxillary first molars minus the distance between the central
groove of maxillary first molars.
SD, Standard deviation.
*Not significant (P .0.05).
of Araraquara Dentistry College (UNESP) containing
cone-beam computed tomography (CBCT) files (pre-
surgery and postsurgery) of 15 patients (10 women
and 6 men) with a mean age of 30.4 years (minimum,
18.7; maximum, 39.7) treated between 2010 and
2012. Patients who had undergone previous ortho-
dontic treatment and who had severe facial defor-
mities or syndromes were excluded. Selection criteria
for both groups were transverse maxillary deficiency
greater than 4 mm associated with unilateral or bilat-
eral crossbite (Table I). The MARPE device used in this
study had a 9-mm jackscrew expander and 4 minis-
crews inserted paramedian to the midpalatal suture
(Peclab, Belo Horizonte, Minas Gerais, Brazil) (Fig 1).
MARPE positioning was planned using initial CBCT
images (T0) so that the miniscrews were inserted in
a region of adequate bone thickness. After successful
expansion, the patients underwent a second CBCT
examination (T1).
The miniscrews were installed manually with a
contra-angle driver (Peclab), and the torque was
measured between 15 N and 20 N. Activation protocol
was a 2/4 turn immediately after mini-implant place-
ment, and 2/4 turns daily on the following days (from
14 to 18 days) until full correction was achieved.
The SARPE group underwent surgery, including Le-
Fort I subtotal osteotomy in the lateral wall of the
maxilla, pterygomaxillary suture, and midpalatal suture
disruption performed under general anesthesia at the
university medical hospital. A hyrax expander was used
with an activation protocol of 1/4 turns (0.2 mm) 2 times
daily until crossbite correction.
CBCTs at T0 and T1 with MARPE and SARPE were
obtained using an i-CAT Next Generation (Imaging Sci-
ences International, Hatfield, Pa) at these settings: 120
kVp; 36 mA; 0.25-mm voxel size; scan time, 7 seconds;
and field view of 13 cm in height 3 16 cm in depth. For
both groups, the data were exported in the Digital
de Oliveira et al
Fig 1. MARPE (A) and SARPE (B) expander devices.
Imaging and Communication in Medicine format and
analyzed using NemoStudio software (Nemotec, Madrid,
Spain). For sample blinding, examiner A (P.A.) coded the
CBCT files, and examiner B was responsible for skeletal
and dental measurements.
The images in 3-dimensional reformatting were posi-
tioned according to 3 spatial orientation planes (sagittal,
coronal, and axial), as shown in Figure 2.
To measure the skeletal effects of expansion in both
groups, linear measurements (in millimeters) of the
maxillary bone structure were obtained in the upper
and lower segments of the maxilla and the anterior
and posterior segments to quantify the transverse
changes in the nasal cavity and evaluate the maxillary
split pattern. To evaluate the dental results, measure-
ments were obtained to quantify the amount of expan-
sion and inclination (Fig 3 and Table II).
Statistical analysis
To determine the intraexaminer error, 40% of the
CBCT scans were reanalyzed randomly by the same
examiner within a 2-week interval. The reproducibility
of the method was evaluated using the intraclass corre-
lation test and a paired t test for the linear and angular
measurements. The intraclass correlation of the linear
and angular measurements was greater than 0.92. The
paired t test showed that the mean variation in the
angular measurements was 0.20 and for the linear mea-
surements was a maximum of 0.14 mm, indicating
excellent intraexaminer reliability.
Shapiro-Wilk and Levene tests verified the
normality of the data distribution and homogeneity
of variances, respectively. The data are shown as the
mean and standard deviation of the variables with a
normal distribution.
RPE using MARPE and SARPE were compared before
and after treatment using a Student t test for dependent
samples. The Student t test for independent samples was
used to evaluate differences between the MARPE and
SARPE groups.
American Journal of Orthodontics and Dentofacial Orthopedics
735
Statistical analysis was performed using SPSS for
Windows (version 16.0; SPSS, Chicago, Ill) with a signif-
icance level of 5% (a 5 0.05).
RESULTS
A significant difference in all skeletal measurements
was found after maxillary expansion with MARPE
(P \0.05). The SARPE results showed a significant
change after expansion in the majority of the skeletal
measurements (P\0.05), with the exception of the mid-
facial width and posterior maxillary base (Table III).
MARPE showed significantly greater expansion in the
midfacial area, nasal cavity, anterior and posterior pal-
ate, and posterior maxillary base than SARPE. No statis-
tically significant difference was found for expansion
between MARPE and SARPE at the level of the alveolar
process and anterior maxillary base (Table III).
The upper (midface area [MIF]) and lower (anterior
palate [AP]) skeletal width effects of MARPE and SARPE
were significant. However, SARPE tended to expand the
palate more than the midface area (MIF had 8% of AP
expansion) in a triangle-shaped opening pattern, and
MARPE resulted in a more parallel expansion of the up-
per midface and anterior palate (MIF had 78% of the AP
expansion) (Fig 4, B and D) (Table IV).
On the palatal plane, the anterior expansion was
significantly greater than the posterior expansion for
both the SARPE and MARPE groups (P\0.05); however,
this difference was much smaller in the MARPE group
(PP-AP 5 0.95 mm) compared with the SARPE group
(PP-AP 5 1.65 mm). At the maxillary base and alveolar
process, the anterior and posterior expansions were sta-
tistically similar for the MARPE group (P .0.05),
whereas for SARPE, a significantly greater anterior
expansion was observed in these measurements
(P \0.05). Taking into account the axial view, these
data showed a more parallel skeletal expansion pattern
in the MARPE group and a triangular-shaped expansion
in the SARPE group, with greater expansion in the ante-
rior region (Fig 4, A and C) (Table IV).
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736 de Oliveira et al

Fig 2. Head position standardization. (A) The coronal view is in the axial plane line over the lower
margin of the right and left orbits and the sagittal plane line coinciding with the nasal, (B) right sagittal
view, and (C) left is a line of the axial plane coinciding with the Frankfurt plane and the coronal plane line
passing through the posterior border of the pallium.

Fig 3. Linear skeletal measurements of an axial slice: (A) MIF and (B) PP and PA; linear skeletal mea-
surements on a coronal slice at the first molar plane: (C) MMW, MNM, and MAW; linear skeletal mea-
surements at first premolar plane: (D) PMW, PNM, and PAW; angular and linear measurements used to
measure the dental effect on the maxillary first molars: (E) IMR, IMC, RMA, and LMA; angular and linear
measurements used to measure the dental effect on the premolars: (F) IPR, IPC, RPA, and LPA.

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de Oliveira et al
Table II. Skeletal and dental measures
Measurements
Skeletal measurements
Axial slice passing through the infraorbital foramina
Axial slice passing through the palatine processing
center
Coronal slice passing through the maxillary right first
molar root apex
Coronal slice passing through the maxillary right first
premolar root apex
Dental measurements
Coronal slice (multiplanar reconstruction to locate
each reference point used in dental measurements)
Regarding the dental effects, all of the measure-
ments of the first molars and first premolars increased
significantly in both the MARPE and SARPE groups
(P \0.05). The SARPE group had more dental changes
(P \0.05) than the MARPE group, except for the root
distance, which showed no difference (P .0.05)
(Table III). The buccal inclination of the molars and pre-
molars after MARPE were similar and the same bilater-
ally. In the SARPE group, although there were no left
and right differences in the dental changes, there was
a significant increase in the first molar inclination
compared with the premolars; the right buccal tip was
60.5%, and the left buccal tip was 67.4% (Table IV).
Figures 5 and 6 show a schematic representation of
the skeletal maxillary expansion patterns of MARPE
and SARPE. SARPE demonstrated a greater transverse
increase at the first molars (IMC, 7.9 mm) than MARPE
(IMC, 5.2 mm). However, as shown in Figure 5, the skel-
etal expansion (2.27 mm) was the effect that most
contributed to this transversal increase in the MARPE
treatment, followed by the transversal expansion of
the alveolar processes (1.59 mm) and 1.39 mm of the
dental expansion. In the SARPE treatment, the higher
American Journal of Orthodontics and Dentofacial Orthopedics
737
Abbreviation Description
MIF Distance between the infraorbital foramina
PP Distance between the greater palatine foramina
AP Distance between the lateral walls of the incisive foramen
MMW Distance between the lateral maxilla walls at the plane
that passes on the nasal floor
MNW Maximum width of the nasal cavity
MAW Greater distance between the maxillary buccal alveolar
processes
PMW Distance between the lateral maxilla walls at the plane
that passes on the nasal floor
PNW Maximum width of the nasal cavity
PAW Greater distance between the maxillary buccal alveolar
processes
IMR Distance between the apex of the palatal roots of the
molars
IMC Distance between the buccal middle molar cusps
RMA Angle between the cusp-apex line of the right molar and
the horizontal plane
LMA Angle between the cusp-apex line of the left molar and
the horizontal plane
IPR Distance between the apex of the palatal roots of the
premolars
IPC Distance between the buccal middle premolar cusps
RPA Angle between the cusp-apex line of the right premolar
and the horizontal plane
LPA Angle between the cusp-apex line of the left premolar and
the horizontal plane
expansion was due to a greater dental (3.86 mm) and
alveolar (3.94 mm) buccal inclination and almost no
skeletal effect. In the anterior area of the maxilla, the
pattern changed slightly, mainly in the SARPE group.
As shown in Figure 6, the skeletal effects of the expan-
sion predominated in the MARPE group, whereas in
the SARPE group, there was an equivalent effect of the
expander represented by an increase in the width at
the maxillary base, alveolar process, and inclination of
the premolars.
DISCUSSION
SARPE or MARPE approaches are recommended to
correct transversal maxillary problems in adults4,7-9 to
increase the skeletal effect and minimize the unwanted
side effects associated with conventional expansion.
The choice should consider the method that produces
the best skeletal effects and the best cost/benefit for
the patient.
On the basis of actual data, MARPE showed signifi-
cantly greater skeletal expansion than SARPE, except
for the alveolar process and anterior maxillary base
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738 de Oliveira et al

Table III. Comparison of the skeletal and dental changes between the MARPE and the SARPE groups after maxillary
expansion
MARPE (n 5 17) SARPE (n 5 15) MARPE SARPE

Area of interest Measurement Mean SD P Mean SD P Mean SEM P (t test) Comparisons

Skeletal
Midfacial area (mm) MIF 2.90 1.20 \0.001* 0.21 0.37 0.051** 2.70 0.31 \0.001* MARPE . SARPE
Posterior palate (mm) PP 2.75 0.85 \0.001* 0.89 0.63 \0.001* 1.86 0.27 \0.001* MARPE . SARPE
Anterior palate (mm) AP 3.69 1.42 \0.001* 2.53 1.48 \0.001* 1.16 0.51 0.031* MARPE . SARPE
Posterior maxillary base (mm) MMW 2.27 1.10 \0.001* 0.11 0.63 0.513** 2.16 0.31 \0.001* MARPE . SARPE
Posterior nasal cavity (mm) MNW 2.92 1.13 \0.001* 1.10 0.80 \0.001* 1.82 0.35 \0.001* MARPE . SARPE
Posterior alveolar process (mm) MAW 3.86 1.20 \0.001* 4.05 1.46 \0.001* 0.19 0.47 0.694** MARPE 5 SARPE
Anterior maxillary base (mm) PMW 3.26 2.58 \0.001* 2.74 1.80 \0.001* 0.52 0.80 0.518** MARPE 5 SARPE
Anterior nasal cavity (mm) PNW 2.89 2.04 \0.001* 0.95 1.56 0.033* 1.94 0.65 0.005* MARPE . SARPE
Anterior alveolar process (mm) PAW 4.30 1.87 \0.001* 5.05 1.96 \0.001* 0.75 0.68 0.277** MARPE 5 SARPE
Dental
U6 root distance (mm) IMR 3.81 1.55 \0.001* 3.31 1.21 \0.001* 0.49 0.50 0.326** MARPE 5 SARPE
U6 cusp distance (mm) IMC 5.25 2.34 \0.001* 7.91 2.00 \0.001* 2.66 0.78 0.002* MARPE \ SARPE
U6 right angulation ( ) RMA 2.87 1.94 \0.001* 7.78 4.05 \0.001* 4.91 1.15 \0.001* MARPE \ SARPE
U6 left angulation ( ) LMA 3.39 2.41 \0.001* 6.82 3.76 \0.001* 3.43 1.10 0.004* MARPE \ SARPE
U4 root distance (mm) IPR 4.03 1.76 \0.001* 4.34 1.99 \0.001* 0.30 0.66 0.649** MARPE 5 SARPE
U4 cusp distance (mm) IPC 5.21 2.25 \0.001* 7.19 2.47 \0.001* 1.98 0.84 0.025* MARPE \ SARPE
U4 right angulation ( ) RPA 1.40 1.74 0.004* 4.71 3.98 \0.001* 3.31 1.11 0.008* MARPE \ SARPE
U4 left angulation ( ) LPA 1.88 2.33 0.004* 4.60 3.61 \0.001* 2.72 1.06 0.016* MARPE \ SARPE

*P \0.05; **Not significant (P .0.05).

SD, Standard deviation.

Fig 4. CBCT images of the MARPE (A and B) and SARPE (C and D) palatal opening and
3-dimensional craniofacial view.

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de Oliveira et al 739

Table IV. Paired t test of the superior-inferior and posterior-anterior skeletal changes and posterior-anterior and
right-left dental changes
Parameters by group Formula Mean SD P
MARPE (n 5 17)
Posterior palate-anterior palate (mm) PP-AP 0.95 0.73 \0.001*
Midfacial area-anterior palate (mm) MIF-AP 0.79 0.76 0.001*
Posterior maxillary base-anterior maxillary base (mm) MMW-PMW 0.98 2.07 0.068**
Posterior nasal cavity-anterior nasal cavity (mm) MNW-PNW 0.03 1.57 0.942**
Posterior alveolar process-anterior alveolar process (mm) MAW-PAW 0.44 1.23 0.164**
U6 root distance-U4 root distance (mm) IMR-IPR 0.22 1.47 0.537**
U6 cusp distance-U4 cusp distance (mm) IMC-IPC 0.04 1.81 0.937**
U6 right angulation-U4 right angulation ( ) RMA-RPA 1.28 2.42 0.05**
U6 left angulation-U4 left angulation ( ) LMA-LPA 1.51 3.09 0.069**
U6 right angulation-U6 left angulation ( ) RMA-LMA 0.51 2.83 0.474**
U4 right angulation-U4 left angulation ( ) RPA-LPA 0.48 2.52 0.451**
SARPE (n 5 15)
Posterior palate-anterior palate (mm) PP-AP 1.65 1.62 0.002*
Midfacial area-anterior palate (mm) MIF-AP 2.33 1.36 \0.001*
Posterior maxillary base-anterior maxillary base (mm) MMW-PMW 2.63 1.62 \0.001*
Posterior nasal cavity-anterior nasal cavity (mm) MNW-PNW 0.15 1.11 0.612**
Posterior alveolar process-anterior alveolar process (mm) MAW-PAW 1.00 1.70 0.039*
U6 root distance-U4 root distance (mm) IMR-IPR 1.02 1.26 0.007*
U6 cusp distance-U4 cusp distance (mm) IMC-IPC 0.72 1.76 0.136**
U6 right angulation-U4 right angulation ( ) RMA-RPA 3.07 3.67 0.006*
U6 left angulation-U4 left angulation ( ) LMA-LPA 2.22 3.31 0.021*
U6 right angulation-U6 left angulation ( ) RMA-LMA 0.95 4.40 0.430**
U4 right angulation-U4 left angulation ( ) RPA-LPA 0.10 3.79 0.919**
*P \0.05; **Not significant (P .0.05).
SD, Standard deviation.

measurements, which demonstrated similar results.
SARPE also showed greater expansion of the palate
than the upper-middle face (MIF had 8% of the AP
expansion), whereas MARPE had an almost parallel
expansion as indicated by the upper midface and ante-
rior palate measurements (MIF had 78% of the AP
expansion).
The parallel pattern found in the MARPE patients
indicated a greater chance of disarticulation of the su-
tures located at the pyramidal process of the palatine
bone and the pterygoid process of the sphenoid bone.
These results were confirmed in the study by Cantarella
et al20 that observed the opening of the midpalatal su-
ture almost perfectly parallel anteroposteriorly using
MARPE (PNS split was 90% of that of ANS). They also
indicated that the lateral and media plates of the ptery-
goid process detached in 53% of the sutures when using
a maxillary skeletal expander (MSE). These effects may
have important implications for the treatment of Class
III malocclusion when facemask therapy is applied
immediately after MARPE expansion, reducing the resis-
tance to maxillary protraction and thus potentiating an-
teroposterior orthopedic outcomes.21
Cantarella et al22 indicated that MARPE appliances
designed with miniscrews placed close to the midpalatal
suture are more favorable for obtaining greater expan-
sion in the midface because the force is applied closer
to the center of resistance of the maxilla. They showed
a significant displacement of the zygomatic bone in a
lateral direction after treatment with an MSE.
The MARPE group had a significant increase in the
width at the anterior and posterior region of the maxilla
and the level of the maxillary base, nasal cavity, and
alveolar process. In contrast, patients treated by SARPE,
even with a surgical approach on the pterygopalatine
suture, had an insignificant posterior maxillary base
expansion, possibly because of the position of the hyrax
expander, more downward but also more forward than
MARPE. Therefore, an evident triangular opening
pattern was observed in the SARPE group, whereas
MARPE produced an almost parallel expansion of the
maxilla when evaluated occlusally.
The SARPE expansion patterns observed in the pre-
sent study corroborate a previous study23 that showed
a consistent pattern of triangular separation of the
maxilla in the coronal plane, with the apex facing the
nasal cavity and the base at the level of the palatal pro-
cess. Tooth-borne expanders such as hyrax produce a V-
shaped opening in the anteroposterior direction, with a
greater opening in the anterior region and the absence

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740
Fig 5. Expansion at the first molars. Contribution of skel-
etal expansion of the maxillary base to the level of the pal-
atine process (MMW), expansion at the level of the
alveolar processes (MAW-MMW), and molar expansion
at the level of the molar cusps (IMC-MAW). For MARPE,
the posterior maxillary base, alveolar process, and molar
expansion were similar (analysis of variance, P .0.05).
For SARPE, analysis of variance showed differences
(P \0.05), and the t test demonstrated a lower expansion
of the maxillary base than the alveolar process and molar
width (P \0.05).
Fig 6. Expansion at the first premolars. Amount contribu-
tion of the skeletal expansion of the maxillary base to the
level of the palatine process (PMW), expansion at the
level of the alveolar processes (PAW-PMW), and premo-
lar expansion at the level of the first premolar cusps (IPC-
PAW). For MARPE, the anterior maxillary base expan-
sion was greater than the alveolar process and dental
expansion (analysis of variance, P .0.05; t test: maxillary
base . alveolar process 5 premolar width). For SARPE,
analysis of variance showed no differences (P .0.05).
of posterior suture disarticulation, especially pterygopa-
latine, as reported in a study by Ghoneima et al.24
Differences in the maxillary opening patterns that
occurred as a result of the expansion were credited to
the expander force line of action. The line of force action
produced by the hyrax expander used in the SARPE
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de Oliveira et al
group was lower than the line of force action provided
by MARPE.
Lin et al9 observed that rapid maxillary expander with
tooth-borne expanders (hyrax) had larger triangular
expansion patterns in the coronal plane than bone-
borne expanders supported by 4 mini-implants (MSE).
Oh et al25 verified that MSE was a superior alternative
method of correcting maxillary skeletal transverse defi-
ciencies because it produced much greater skeletal
changes than a tooth-anchored expander (hyrax) or a
bone-anchored expander placed in the palatal vault be-
tween the first molar and second premolar roots 6 mm
away from the suture.
Another characteristic observed in the present study
was a greater expansion at the dental and alveolar pro-
cess area for SARPE than MARPE, with a higher expan-
sion at the maxillary base and a smaller expansion of the
alveolar processes and intermolar cuspids, respectively.
Both methods showed an increase in the intermolar
and interpremolar distances at the root and cusp level.
Although the root distances were not different between
the groups, SARPE produced a greater increase in the in-
termolar and interpremolar distance when measuring at
the tooth cusp level than MARPE. Similarly, tooth angu-
lation outcomes showed a significant increase in buccal
tipping in SARPE compared with MARPE.
Chung and Goldman26 reported side effects of SARPE
of up to 7 of maxillary first molar buccal inclination.
The authors suggested that side effects produced by
tooth-borne appliances in this technique include
compression of the periodontal ligament, which may
lead to resorption of the alveolar bone and possible
loss of alveolar bone crest height. A subsequent clinical
study confirmed the negative periodontal impact of
this appliance.27
The present study found an average of up to 3.3 of
buccal tipping in the supporting teeth in the MARPE
group, which was half of the buccal tipping presented
by the SARPE group. The dental inclination may have
been minimized in the MARPE group because this
expander may be considered a hybrid device.
Park et al28 found a significant molar buccal inclina-
tion of 5.8 when using a hybrid expander, a modified
hyrax appliance with bone support of 4 miniscrews in
20-year-old patients. Cantarella et al22 found an insig-
nificant mean dental inclination of 2.04 for the right
molar and 1.83 for the left molar using an MSE device.
A finite element study29 showed minimal inclination of
the posterior teeth with MARPE, which may lead to bet-
ter vertical control, suggesting that MARPE may be
beneficial for adults and patients with dolichofacial
abnormalities.
de Oliveira et al
In adult patients, SARPE widens the upper airway
space and decreases airway resistance, increasing expira-
tory and inspiratory flow.30,31 However, Zandi et al32
showed insignificant changes in anterior and posterior
nasal expansion with tooth-borne distractors (1.61 mm
and 1.54 mm) and bone-borne distractors (1.47 mm
and 1.33 mm) in SARPE treatments. In the aforemen-
tioned study,32 the tooth-borne and bone-borne ex-
panders used for SARPE were positioned more
downward compared with MARPE.
The current results found significantly higher nasal
cavity expansion values for MARPE (MNW, 2.92 mm;
PNW, 2.89 mm) than SARPE (MNW, 1.10 mm; PNW,
0.95 mm). The difference in the increase in the nasal cav-
ity width between the groups may be attributed to the
expansion patterns obtained using each method, more
parallel in the MARPE group and more triangular (or py-
ramidal) in the SARPE group.
The significantly greater enlargement of the nasal
cavity verified using MARPE compared with SARPE
may have a more positive impact on the upper airway,
according to Bazargani et al,33 who demonstrated an in-
crease in nasal airway flow and a decrease in the air resis-
tance in young patients (aged 8-13 years) treated with
tooth-bone-borne expander. Storto et al34 concluded
that the skeletal changes after MARPE directly affected
airway measurements, resulting in a significant improve-
ment in muscle strength and nasal and oral peak flow in
mature patients. A case report showed that by increasing
airway dimensions, the overall respiratory function
might have improved in a swimmer, which had a positive
effect on his physical tests and sports performance.35
More studies should be conducted to better evaluate
the potential of MARPE and SARPE to increase airway
dimensions and benefit patient health and daily life.
CONCLUSIONS
On the basis of this study’s results, we conclude the
following:
1. MARPE showed an increase in skeletal transverse
maxillary expansion at the palate and basal bone
compared with SARPE, especially at the posterior re-
gion. No difference was found in the expansion of
the alveolar process between the 2 methods.
2. MARPE presented a more parallel expansion in both
the coronal and axial view, whereas SARPE resulted
in a more triangular and V-shaped opening.
3. A greater buccal inclination of the alveolar process
and supporting teeth was observed in the SARPE
group.
American Journal of Orthodontics and Dentofacial Orthopedics
741
AUTHOR CREDIT STATEMENT
Cibele Braga de Oliveira contributed to conceptuali-
zation, methodology, investigation, project administra-
tion, data curation, and original draft preparation;
Priscila Ayub contributed to resources; Ingrid M€uller Le-
dra contributed to investigation; Wilson Humio Murata
contributed to resources; Selly Sayuri Suzuki contributed
to resources and draft review and editing; Dirceu
Barnabe Ravelli contributed to resources; and Ary
Santos-Pinto contributed to formal analysis, draft re-
view and editing, and supervision.
ACKNOWLEDGMENTS
The authors thank Professor Eduardo Sanches
Gonçalves, Department of Stomatology, School of
Dentistry, S~ao Paulo University, Bauru, and Professor
Valfrido Ant^onio Pereira Filho, Department of Diagnos-
tics and Surgery, Dental School of Araraquara, S~ao Paulo
State University Julio de Mesquita Filho, S~ao Paulo,
Brazil.
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