ORIGINAL ARTICLE

Would midpalatal suture characteristics

help to predict the success rate of
miniscrew-assisted rapid palatal
expansion?
Adriana Souza de Jesus,a Cibele Braga de Oliveira,a Wilson Humio Murata,b Selly Sayuri Suzuki,b
and Ary dos Santos-Pintoa
Araraquara and Campinas, S~ao Paulo, Brazil

Introduction: The objective of this study was to evaluate whether the success or failure of miniscrew-assisted
rapid palatal expansion (MARPE) in patients with advanced bone maturation could be related to factors such as
midpalatal suture density (MPSD), midpalatal maturation stage (MPSM), midpalatal bone thickness (MBTh),
palatal length (PL), expander screw position (ESP), and patient's age. Methods: Cone-beam computed tomog-
raphy scans of 25 patients of both sexes, aged 15-37 years (23 6 7.2), presenting transverse maxillary defi-
ciency and complete skeletal maturation (cervical vertebral maturation stage 5) treated using MARPE were
evaluated. The success of MARPE was confirmed by the midpalatal suture opening and failure when no opening
or limited separation of midpalatal suture occurred. Data were analyzed using t test for independent samples for
differences in the variables of success and failure cases and the Pearson correlation test to evaluate the relation
of the success and age, ESP, MPSD, MPSM, PL, and MBTh. Results: Age, MPSM, and MBTh at 12 mm and
16 mm presented statistically significant results (P\0.05). The older the patient with advanced bone maturation,
the lower the success rates of MARPE (94.1%, 90%, and 76% for 25, 30, and 37 years, respectively). The ESP
had similar averages in cases of success (15.34 mm) and failure (13.51 mm). There was no correlation between
ESP, MPSD, MPSM, or PL and MARPE success. Conclusions: MARPE success was related to age and a
greater MBTh at 12 mm and 16 mm. (Am J Orthod Dentofacial Orthop 2021;160:363-73)

R
apid maxillary expansion (RME) is the standard
treatment method for patients presenting trans-
verse deficiency of the maxillary bone. In this
treatment modality, expanders are used to apply lateral
forces to the teeth, which increases the perimeter of
the arch and disarticulates the midpalatal suture
(MPS). Later, a reorganization at the suture occurs by
connective tissue repair and bone formation.1,2
a
Department of Orthodontics, School of Dentistry, S~ao Paulo State University,
Araraquara, S~ao Paulo, Brazil.
b
Department of Orthodontics, S~ao Leopoldo Mandic School and Dental Institute,
Campinas, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
The authors acknowledge the Coordination for the Improvement of Higher Ed-
ucation Personnel for financial resources for this research.
Address correspondence to: Adriana Souza de Jesus, Department of Orthodon-
tics, School of Dentistry, S~ao Paulo State University, Rua Humaita 1680, Centro,
Araraquara, S~ao Paulo 14801-385, Brazil; e-mail, jesus.adrianasouza@gmail.
com.
Submitted, December 2019; revised and accepted, April 2020.
0889-5406/$36.00
Ó 2021.
https://doi.org/10.1016/j.ajodo.2020.04.035
Previous studies have shown that about 10% of the
total population and 30% of adult orthodontic patients
have some transverse maxillary deficiency related to a
posterior crossbite.3-5 MPS disarticulation can be easily
achieved in young children; meanwhile, in adult
patients, this suture presents increasingly complex
interdigitation, which makes it more challenging to
split.6 Both midpalatal and circummaxillary sutures
initiate the ossification process approximately in late
adolescence and become more rigid with advancing
age.7,8 When performing maxillary expansion in patients
with more advanced bone maturation, widening of the
maxillary width tends to result in greater alveolar bone
flexion and dental inclination.9 In addition, associated
undesirable effects may include buccal alveolar fenestra-
tions, no MPS split, alveolar bending, extrusion of pos-
terior teeth, pain, instability, and root resorption.10
Miniscrew-assisted rapid palatal expander (MARPE)
technique reported by Lee et al11 emerged as a clinically
effective and stable approach for nonsurgical correction
of transverse discrepancy in adult patients.12,13 Clinical
studies have been demonstrating successful results
363
364 Jesus et al

using MARPE in adults.14,15 However, in some patients
with MARPE, orthopedic maxillary expansion may not
occur. It is still unclear the reasons related to MARPE
failure, but differences in calcification patterns of the
MPS and craniofacial architecture (higher resistance)
may play a role as contributing factors.11,13
A retrospective clinical study by Choi et al13 showed
as age increases, the amount of dentoalveolar expansion
tended to be greater in relation to the orthopedic effects
of maxillary expansion. The authors stated that, in older
patients, the rigidity of the craniofacial skeleton could
limit the skeletal effects of MARPE. Therefore, the pre-
dictability of success should be well explained to the
patient because MARPE is still susceptible to failure.
In clinical practice, it is difficult to predict the success
of MARPE in adult patients. A method to maximize the
effects of the MARPE technique in clinical situations has
not been fully studied.14 In this sense, it seems relevant
to study the factors that may be associated with the suc-
cess or failure of the MPS opening in these patients to
better predict the outcome of the expansion procedure.
This research aimed to evaluate whether the success
or failure of MARPE in patients with advanced bone
maturation is related to factors such as midpalatal
bone density (MPSD), maturation stage (MPSM), palatal
length (PL), bone thickness (MBTh), expander screw po-
sition (ESP), and patient's age.
MATERIAL AND METHODS
The sample used for this retrospective controlled
study included cone-beam computed tomography
(CBCT) scans of 25 patients aged between 15 and
37 years (mean, 23 6 7.02), treated with MARPE.
Table I shows the sample distribution.
The inclusion criteria were CBCT's before (T0) and af-
ter maxillary expansion (T1) of subjects presenting
transverse maxillary deficiency with unilateral or
bilateral posterior crossbite (a difference greater than
5 mm between the transverse distance of the palatal
cusps of the maxillary first molars and the transverse dis-
tance of the first mandibular molars central sulcus) with
complete skeletal maturation confirmed by examination
of the cervical vertebrae. All subjects were in cervical
vertebral maturation stage 5 of Hassel and Farman's
analysis modified by Baccetti, Franchi, and McNamara.16
Patients with previous orthodontic treatment, cleft lip
and palate, and syndromic conditions were excluded.
Four patients that met the inclusion criteria (success
cases) were excluded because the MARPE appliance
was in place on the initial tomographic evaluation, re-
stricting the visualization of bone structures for mea-
surements.
Patients were treated by RME using a hybrid
expander device supported by 4 orthodontic miniscrews
inserted paramedian to the MPS and attached to the
molars (PecLab, Belo Horizonte, Minas Gerais, Brazil)
(Fig 1). MARPE positioning and miniscrew sizes were
planned using initial CBCT images (T0), considering
the bone thickness and the available palate space to
accommodate the expander device.
All miniscrews were inserted manually with a manual
contra-angle driver (PecLab). To measure the insertion
torque, a torque wrench was used. All steps were per-
formed by the same clinician (C.B.O.).
The activation protocol was two-fourth turn immedi-
ately after MARPE placement and two-fourth turn daily
on the following days (one-fourth in the morning and
one-fourth at night), varying from 14 to 18 days until
full correction was achieved. After expansion, the
expander screw was locked and kept in place, without
activation, for the following 4 months.
CBCT scans before (T0) and after (T1) expansion were
taken using the i-CAT Next Generation scanner (Imaging
Sciences International, Hatfield, Pa) at these settings: 36

Table I. Sample description according to treatment effect, sex, age, MPSM, and the tomographic indicators to assess
the success of the orthopedic expansion of MARPE technique (difference between preactivation and postactivation)
Age MPSM stage MIF PP AP

Treatment effect Sex n Mean SD Min Max B C D E Mean SE Mean SE Mean SE

Success Male 7 15 26 2 1 1 3
Female 12 15 34 1 4 3 4
Both 19 20.6 5.32a 15 34 3 5 4 7 2.83a 0.27 2.70a 0.20 3.47a 0.33
Failure Male 1 31 31 1
Female 5 17 37 2 3
Both 6 30.6 7.42b 15 34 2 4 0.47b 0.16 0.61b 0.20 0.71b 0.24
Note. Test t bicaudal (P \0.05). Significance is indicated by superscript letters for mean age (a \ b) and for the mean of variables MIF, PP, and AP
(a . b). Pearson chi-square for stages of MPSM (P 5 0.671).
MIF, the distance between infraorbital foramen; PP, distance lateral walls between the greater palatine foramina; AP, distance lateral walls of the
incisive foramen in millimeters); SD, standard deviation; Min, minimum; Max, maximum.

September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jesus et al
Fig 1. The MARPE: A, two anterior miniscrews, size
1.8 mm size in diameter with transmucosal of 4 mm and
7 mm of length; B, the 2 miniscrews were of 1.8 mm
size in diameter with 4 mm of transmucosal and 5 mm
of length.
mA, 120 kV, exposure time of 7 seconds, voxel size of
0.25 mm, axial slice thickness of 0.5 mm, and scanning
area of 23 3 17 cm. Data were exported in the digital
image and communication in medicine format. All
CBCTs were taken before bonding brackets or any other
apparatus.
The success of the orthopedic expansion of the
maxilla with MARPE was confirmed by the opening of
the medial palatine suture observed by the separation
of the two halves of the palatine process confirmed in
the tomographic examination after the activation
period. Treatment failure was defined when the separa-
tion of the MPS was not observed in the tomographic ex-
amination. In patients in which moderate MPS
separation was observed anteriorly but the posterior
portion of the palate did not show significant changes
(# 1.0 mm), it was considered a limited result and
included as a failure of the technique. Maxillary changes
were obtained by the difference of the linear measure-
ments achieved (T1 T0). The images were oriented
as Figure 2, A-C, and the measure was made in axial slice
(MIF, the measurement between infraorbital foramen;
PP, lateral walls between the greater palatine foramina;
AP, lateral walls of the incisive foramen). The measure-
ments (Table I) were used to separate the samples by suc-
cess and failure because the expansion values of success
were statistically higher than failure.
Initial examinations (T0) of each patient were used to
evaluate the MPSD ratio. CBCT images were oriented us-
ing Dolphin 3D software (Dolphin Imaging and Manage-
ment Solutions, Chatsworth, Calif) to adjust the palatal
plane in the sagittal and frontal views to yield an axial
slice through the center and parallel to the hard palate.
American Journal of Orthodontics and Dentofacial Orthopedics
365
After orientation, the scans were exported and saved
in digital image and communication in medicine format.
After that, gray density measurements were performed
using Mimics software (version 21.0; Materialise,
Leuven, Belgium), with a cut thickness of 0.5 mm.
Average gray density values were determined following
the protocol previously described in the study of
Gr€unheid et al.17 Regions of the suture (GDs), soft palate
(GDsp), and palatal process of the maxilla (GDppm) were
defined (Fig 2), and average gray density values were
used to calculate the MPSD ratio by the following equa-
tion.
GDs GDsp
MPSD ratio 5
GDppm GDsp
Dolphin 3D software was used to measure MBTh, PL,
MPSM, and the MARPE screw position in all T0 images.
To determine the MBTh, images were oriented as
Figure 3. In the sagittal view, the posterior wall of the
incisive foramen and the posterior nasal spine was posi-
tioned to pass throughout the same horizontal plane.
The MBTh was measured perpendicular to the horizontal
plane at intervals every 4 mm from the incisive foramen
to the posterior limit of 32 mm (Fig 3, C).
The PL was performed following the protocol previ-
ously described in the study of Shin et al18 and defined,
in axial view, as the distance from the posterior border of
the incisive foramen to the line formed by the coronal
slice passing through the posterior nasal spine in the
sagittal plane (Fig 4).
To determine the MPSM of the patients, the T0 image
was used. The classification protocol for the MPS matu-
ration was according to Angelieri et al,6 which can be
classified into 5 stages: A, B, C, D, or E. The images
were cut out and arranged in the PowerPoint program
(Microsoft, Redmond, Wash), standardized on a black
background, and coded for classification.
The position of the expander screw was measured in
the axial view, from the distal aspect of the incisor fora-
men to the center of the expander screw (measure D For-
ame-Screw) using the T1 image (Fig 5).
Statistical analysis
Estimation of the sample size was performed with
G*power software (version 3.0.10; Franz Faul University,
Kiel, Germany) for a 2-tailed t test and effect size of 0.8
and correlation test and effect size of 0.5, both with an
alpha of 0.05 for a group of 25 patients resulted in a po-
wer of 97% and 80%, respectively.
To determine the intraexaminer error calculation, all
scans were reanalyzed randomly by the same examiner
(A.S.J.), with a 2-week interval between the first and
September 2021  Vol 160  Issue 3
366 Jesus et al

Fig 2. Views of the 3-dimensional reconstructions in Mimics software after preorientation in Dolphin
Software: sagittal (A) and frontal (B) views used to orient the hard palate parallel to the true horizontal;
C, central slice used for measurements. Regions used to determine average gray density values: D, the
gray density of the suture was determined in a rectangle centered on the MPS from the distal aspect of
the incisive foramen to the distal aspect of the first molar crown; E, the gray density of the palatal pro-
cess of the maxilla was determined in a square predetermined by the software at the cortical portion of
the palatal process of the maxilla; F, the gray density of the soft palate was determined in the same
square in a posterior area representing the soft palate.

second evaluation. To enable sample blindness, exam-
iner A encoded the tomographic scans, and examiner B
was responsible for the skeletal measurements and clas-
sification of the MPSM stage. The reproducibility of the
method was evaluated using the intraclass correlation
coefficient (ICC) and t test for repeated measures (sys-
tematic error evaluation) for all measures used in this
study. The consistency of the suture classification
method was analyzed by intraexaminer error analysis
(kappa test).
To verify the normality of the data, the Shapiro-Wilk
test was used. Mean and standard deviation were calcu-
lated for the variables with normal distribution. Median
and 95% confidence interval (CI) values were calculated
for the variables that did not exhibit a normal distribu-
tion. Data were analyzed using the t test for independent
samples to evaluate differences in the variables between
cases of success and failure of the maxillary expansion.
The correlation of the success of the maxillary expan-
sion according to the age, ESP, MPSD, MPSM, PL, and
MBTh of the MPS were observed using the Pearson cor-
relation test. For this statistical analysis, the ordinal scale
of MPSM was converted to the numerical variable in
which stage A 5 1, B 5 2, C 5 3, D 5 4, and E 5 5.
The level of significance adopted for the rejection of
the hypotheses examined was 0.05. The calculations for
the statistical analysis were performed using SPSS statis-
tical software (version 16; SPSS, Chicago, Ill).
RESULTS
The intraexaminer error calculation obtained by the
ICC (Cronbach a ICC) for replicate measurements ranged
from 0.953 (95% CI, 0.891-0.980) to 0.998 (95% CI,
0.996-0.999), indicating excellent intraexaminer reli-
ability. Complementary t tests for paired samples applied
to replicate measurements were not significant, and the
mean difference ranged from 0.04 (standard error [SE],
0.03) to 0.18 (SE, 0.17), showing no systematic error in
the measurements.
The kappa test to analyze the consistency of the
MPSM stage resulted in 0.768 (SE, 0.102) with a 95%
CI ranging from 0.568 to 0.968. The number of observed
agreements was 21 (84% of observations) and the num-
ber of agreements by chance was 7.8 (31% of the

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Jesus et al 367

Fig 3. Orientation of the 3-dimensional reconstructions in Dolphin Imaging software: A, coronal view
used to orient the hard palate perpendicular to the true vertical; B, axial view; C, sagittal section through
the center of the palate, with MBTh measurements every 4 mm behind the incisive foramen.

observations), which represents a substantial agreement
for both measurements.
Mean values, standard deviations, and ranges of the
continuous dependent variables measured are shown in
Table II. Statistically significant associations were found
for the variables age (P 5 0.001), MPSM (P 5 0.014),
and MBTh at the interval from 12 mm to 16 mm behind
the incisor foramen (P 5 0.016 and P 5 0.014, respec-
tively). MARPE failure cases consisted of patients with
older mean age and higher MPSM compared with the
younger mean age and lower MPSM of the success cases.
The MBTh pattern is illustrated in Figure 6. A pattern
of decrease in thickness in the region from 4 mm to
16 mm posterior to the incisive foramen followed by
an increase from 16 mm to 24 mm was observed in
both groups. The success cases showed a slightly smaller
decrease in thickness than the failure cases. A signifi-
cantly greater MBTh (from 5.31 mm to 5.17 mm) in
the region 12 mm to 16 mm posterior to the incisive fo-
ramen was found in the success group than the failure
cases (1.76 mm to 2.01 mm).
The position of the expander screw had similar aver-
ages in the cases of failure (13.51 mm) and success cases
(15.34 mm). There is no statistically significant relation-
ship between the position of the expander screw and the
successful opening of the MPS. The distribution of the
different stages of sutural maturation in the sample is
shown in Table I. Figure 7 illustrates the success and fail-
ure cases of MPS opening in MARPE therapy according
to the MPSM and patient's age.

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368 Jesus et al

Fig 4. Measurements of PL in Dolphin Imaging software: A, orientation of the head in coronal view
showing the horizontal line connecting both infraorbital lower borders; B, orientation of the head in
sagittal view, using the Frankfurt horizontal plane; C, positioning the cuts for PL in a sagittal view
with the axial cut passing through the incisive foramen and the coronal cut passing through the poste-
rior nasal spine; D, measure of the PL, from the posterior border of incisive foramen to the horizontal line
made by coronal plane through the posterior nasal spine sagittally.

Fig 5. Orientation of the 3-dimensional reconstructions in Dolphin Imaging software: A, in the sagittal
view, the horizontal slice in the center of the expander parallel to the palatal plane; B, axial view
showing the measurement of the ESP.

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Jesus et al 369

Table II. Intervening factors for the success or failure of the MPS opening
Failure Success Difference 95% CI Levene t test

Variable n Mean SD n Mean SD Mean SE Lower Upper F P t DF P

Age (y) 6 30.67 7.42 19 20.63 7.42 10.03 2.73 4.37 15.70 0.196 0.662 3.666 23 0.001
MPSM stage 6 4.67 0.52 19 3.74 1.19 0.93 0.34 0.21 1.65 7.163 0.013 2.698 20.2 0.014
MPSD ratio 6 0.78 0.18 19 0.73 0.18 0.05 0.08 0.12 0.22 0.526 0.475 0.616 23 0.544
PL 6 36.41 3.09 19 35.55 2.90 0.86 1.38 1.99 3.72 0.007 0.935 0.628 23 0.536
D Forame-Screw (mm) 6 13.51 2.39 19 15.34 2.09 1.83 1.01 3.92 0.26 0.077 0.783 1.812 23 0.083
MPSD 4 (mm) 6 6.61 2.00 19 6.27 1.52 0.34 0.77 1.25 1.93 0.685 0.416 0.438 23 0.665
MPSD 8 (mm) 6 4.98 1.22 19 6.30 1.55 1.32 0.70 2.76 0.12 1.579 0.221 1.897 23 0.070
MPSD 12 (mm) 6 3.55 1.35 19 5.31 1.47 1.76 0.68 3.16 0.36 0.034 0.854 2.601 23 0.016
MPSD 16 (mm) 6 3.16 1.30 19 5.17 1.69 2.01 0.75 3.78 0.45 0.918 0.348 2.660 23 0.014
MPSD 20 (mm) 6 4.49 1.85 19 5.75 2.01 1.26 0.92 3.18 0.65 0.082 0.778 1.363 23 0.186
MPSD 24 (mm) 6 5.12 2.16 19 6.15 1.65 1.04 0.83 2.75 0.68 0.190 0.667 1.247 23 0.225
MPSD 28 (mm) 6 4.54 2.19 19 5.24 1.80 0.70 0.88 2.54 1.13 1.454 0.226 0.794 23 0.435
MPSD 32 (mm) 6 4.35 2.30 19 4.41 1.62 0.06 0.94 1.79 1.67 2.348 0.139 0.070 23 0.945

SD, Standard deviation.

Fig 6. MBTh (sagittal view) according to MARPE therapy effect.

According to the results of the Pearson correlation
test, age correlated negatively with the success of
MARPE (ie, success decreases with increasing age)
(Table III). The number of success and failure cases ac-
cording to the age of the patients is shown in
Figure 8. For MPSD, MPSM, and PL, no correlation to
success or failure was observed. Regarding bone thick-
ness in the 12 mm and 16 mm regions behind the incisor
foramen, positive correlations were observed with the
success of MARPE.
DISCUSSION
Given the limitation of orthopedic results and the
uncertain prognosis of conventional RME in late adoles-
cence,9 a personalized assessment of a patient's bone
characteristics in the area of interest would be an impor-
tant success predictor of RME. The present study used
MARPE as an alternative treatment for maxillary atresia
in patients with advanced bone maturation and corre-
lated the success of the MARPE technique with MPSD,
MPSM, PL and MBTh, ESP, and patient's age.
The overall success rate of midpalatal opening
(MARPE success) in this sample was 76%, of which 19
out of 25 patients achieved significant skeletal expan-
sion. Choi et al13 observed in their study a success rate
of 87% in a sample of 69 patients aged 18-28 years
treated by RME assisted by a Hyrax device supported
by 4 miniscrews. Our study showed a lower success
rate; however, the age range was higher (patients aged
up to 37 years).

American Journal of Orthodontics and Dentofacial Orthopedics September 2021  Vol 160  Issue 3
370 Jesus et al

Fig 7. The number of success and failure cases of MPS opening in MARPE therapy according to pa-
tient's age.

Table III. Correlation between the success of MARPE, MPSM. All patients that were classified in the B or C
age, MPSD, MPSM, PL, and MBTh stage of MPSM were successfully treated. Considering
stages D and E, the results are not clearly correlated
Success Age MPSD ratio with success or failure. From 17 patients with stages D
Pearson correlation r P r P r P or E of maturation, success was observed in 11 of
Success 0.61 0.001 0.13 0.544 them, all aged up to 28 years, and the highest concentra-
Age 0.61 0.001 0.12 0.584 tion of failures occurred in patients aged close to or over
MPSD ratio 0.13 0.544 0.11 0.584 30 years, except for 1 patient aged 17 years.
MPSM stage 0.36 0.080 0.07 0.752 0.08 0.971
PL 0.13 0.536 0.78 0.712 0.25 0.225
The classification proposed by Angelieri6 from A to E
D Forame-Screw 0.35 0.085 0.33 0.111 0.02 0.949 indicated that the synostosis of the MPS progresses from
MPSD 4 0.90 0.665 0.31 0.132 0.03 0.877 the posterior to the anterior region following the pattern
MPSD 8 0.37 0.070 0.41 0.044 0.07 0.724 showed by Persson and Thilander.19 Consequently, it is
MPSD 12 0.48 0.016 0.50 0.010 0.10 0.635 understood that the posterior region will have a poten-
MPSD 16 0.48 0.014 0.31 0.138 0.04 0.866
MPSD 20 0.23 0.186 0.13 0.544 0.13 0.527
tial increase in resistance to opening the MPS. Despite
MPSD 24 0.25 0.225 0.09 0.687 0.11 0.615 this, our results showed 4 failure cases that were in stage
MPSD 28 0.16 0.435 0.07 0.726 0.06 0.780 E and 7 success cases in the same stage E. In addition,
MPSD 32 0.02 0.945 0.15 0.466 0.03 0.881 there was almost the same proportion of patients in
stage D (2 failures and 4 success), which may explain
why a significant correlation of success with MPSM
In the current study, MARPE failure cases occurred in stage was not found (Table III) and, therefore, other
patients with older mean age (30.6 years) when related factors may influence the failure of MARPE in
compared with the younger mean age (20.6 years) these patients.
(Table II). The correlation test showed that the older The study by Shin at al18 indicated that age, PL, and
the patient, the lower is the expansion success rate MPSM stage could be predictors of midpalatal suture
(P 5 0.001) (Table III). In addition, Figure 8 highlights expansion by MARPE in young adults. They also
a decrease in success rate with 94.1%, 90%, and 76% analyzed the variables density and palate depth.
in patients aged up to 25 years, 30 years, and 37 years, Comparing with the results of the current study, Shin
respectively. One patient aged 17 years had failure indi- at al18 also showed a strong correlation with age as a pre-
cating that the possibility of failure even in young pa- dictor and agree that suture density is not relevant. How-
tients cannot be excluded. Therefore, it is possible to ever, the other variables are not in line with our results
consider individual variability in the results of this ther- despite the similar sample number. Methodologically
apy, and that age alone may not be the only factor to they compared the variables with the amount of opening
safely determine MARPE prognosis. in each patient, whereas we compared with groups of
The results also pointed out that failure cases pre- success and failure of therapy with MARPE, which may
vailed in patients with a higher MPSM than a lower have contributed to the difference in the results.

September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jesus et al
Fig 8. Success and failure cases of MPS opening in MARPE therapy according to MPSM and patient's
age.
Literature has shown that palatal bone densities are
higher in nongrowing than in growing patients20 or
significantly higher in adults than in adolescents.21
The study by Gr€ unheid et al17 intending to find a predic-
tor factor of the skeletal response to conventional RME,
showed that the MPSD ratio has the potential to become
a useful clinical predictor of the skeletal response to
RME. The results of the present study did not confirm
this assumption for MARPE because there was no corre-
lation between midpalatal bone density (MPSD) and the
success of the midpalatal suture opening (Tables II and
unheid et al17 correlated success and failure cases
III). Gr€
of conventional expansion using a dentosupported
appliance.17 In patients treated with MARPE, density
does not interfere, probably because the forces trans-
mitted by MARPE act differently from dentosupported
appliances, as shown previously in finite element
studies.22 Furthermore, there were no differences in
the MPSD ratio in the success and failure cases (Table II).
Shin et al,18 found an association of palate length be-
tween the separation and nonseparation groups treated
with MARPE and explained this association through the
MPS pattern of synostosis was shown to progress from
the posterior to the anterior region.19 Hence, in patients
with a longer palate length, the suture expansion in the
anterior region could be delayed. However, our results
indicated that PL was not associated with the success
of MARPE therapy. The PL had similar mean values in
the patients of failure and success (36.4 mm and
35.5 mm, respectively).
Another variable that could influence the success
of the therapy was the position of the expander screw,
but the results showed no such association
American Journal of Orthodontics and Dentofacial Orthopedics
371
(D Forame-Screw, 13.5 mm and 15.3 mm, respectively
in patients of MARPE failure and success). Although
no significant correlation was found between the posi-
tion of the expander screw and the successful opening
of the MPS, we found that it remained positioned in
the range of 12-16 mm posterior to the incisive foramen,
in which bone thickness showed positive correlations
with the successful patients (Tables II and III). The results
suggest that greater bone thickness in the MPS region
may not lead to greater resistance to suture separation
in the MARPE technique. In addition, it can be argued
that the higher palatal thickness should favor the pri-
mary stability of miniscrews and the consequent
improvement in MARPE expander anchorage, which
may contribute to the success of this therapy. However,
the present study cannot confirm this because the
measured region was the MPS and not the parasutural
region where the miniscrews are precisely positioned.
Studies on palatal bone thickness are mostly focused
on the determination of the best place to anchor minis-
crews and do not relate bone thickness to the resistance
of sutural opening.20,23,24 Regarding miniscrew stability
when inserted into the palatine region surrounding the
MPS, Gracco et al,23 searching the most suitable region
of the palate for miniscrew placement, analyzed the
CBCT images of 162 patients aged from 10 to 44 years
and measured the thickness of the palatal bone at 20
sites. They found a continuous decrease in the MBTh
with no difference among different age groups and
concluded that the thickest part of the palate is the ante-
rior region (mean, 8.66 mm), although bone thickness in
the posterior region (mean, 4.02 mm) may also be suit-
able for screws of appropriate diameter and length.
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The present study found a different pattern of MBTh
in the success cases, starting with a thicker anterior
cortical bone in the region 4-8 mm behind the incisor fo-
ramen (6.27 mm and 6.30 mm) and decreasing progres-
sively in the region from 8 mm to 16 mm (6.30 mm,
5.31 mm, and 5.17 mm) posterior to the incisor foramen.
Then, a progressive increase in the MBTh through the re-
gion 16 mm to 24 mm (5.17 mm, 5.75 mm, and
6.15 mm) and another progressive decrease up to the re-
gion 32 mm behind the incisor foramen (6.15 mm,
5.24 mm, and 4.41 mm). Regarding the failure cases,
we found a similar pattern but decreasing in thickness
just after region 4 mm behind the foramen and an over-
all reduced thickness in relation to success cases with a
significant difference in the 12 mm and 16 mm regions
(Table II).
Yadav et al20 compared MBTh in the anterior, middle,
and posterior parts of the palate in growing and
nongrowing men and women. They also found that
MBTh decreased from the anterior palate region
(mean, 8.29 mm in men; mean, 6.79 mm in women) to-
ward the posterior palate region (mean, 4.15 mm men;
mean, 4.31 mm in women). They concluded that palatal
bone thickness was greater in the anterior part of the
palate (between the canine and first premolar) and rec-
ommended it to have a greater bone miniscrew contact
area; thus, increasing miniscrew primary stability.
Conversely, Ryu et al24 compared bone thickness of the
palatal area in early and late mixed and early permanent
dentitions according to dental age and observed an in-
crease in thickness at the MPS area in all 3 groups.
The results showed that the MBTh is related to the
greater success of MARPE therapy, regardless of factors
such as density and length of the palate (Tables II and
III). There was a significant correlation of bone thickness
from 12 mm to 16 mm behind incisor foramen and the
success of this therapy. That region was 1.8 mm to
2.0 mm thinner in cases of failure (Table II). Overall,
the MBTh is greater in cases of success than in cases
of failure (Fig 6) and does not cause greater resistance
to its separation in the MARPE technique. This is the first
time that this variable is studied, and the result found
about the MBTh region has important clinical signifi-
cance for prognosis and represents a relevant factor in
the success of MPS opening with MARPE.
We consider that the limitation of the current study
was its retrospective design, in which a convenience
sample was used, and in which generalizations consid-
ering the total population should be made with caution.
The amount of expansion was adapted and not stan-
dardized for each patient. Ideally, each patient should
need the same amount of expansion. Nevertheless, the
September 2021  Vol 160  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Jesus et al
activation protocol was standardized for all subjects
overcoming these limitations.
The authors believe that the amount of bone support
is crucial for miniscrew stability and, therefore, to in-
crease the chances of success of MARPE therapy. There-
fore, the preexpansion CBCT examination is indicated as
an important tool to determine the proper positioning of
the MARPE device in each patient, searching for regions
of greater MBTh. Although other factors such as MPSD,
MPSM, and PL were not significantly correlated to
MARPE success, more studies with a larger sample in
each group will be necessary to reassess the correlation
of these variables with the MPS opening. In addition,
more studies should be performed using CBCT images
to evaluate other facial bone structures.
CONCLUSIONS
1. The findings over the success of MARPE therapy in
patients with advanced bone maturation have
shown that the older the patient, the lower the suc-
cess rates in opening the MPS with MARPE.
2. Until 25 years old, the success rate expected with
MARPE treatment is 94.1%. Up to 30 years, the suc-
cess rate decreases to 90% and 76% up to 37 years.
3. Greater midpalatal bone thickness in the regions
12 mm to 16 mm behind the incisor foramen repre-
sents a relevant factor in the success of opening the
MPS with MARPE.
4. MPSD, MPSM, PL, and ESP were not related to the
sutural opening resistance because there was no
correlation between these variables and the success
of the MARPE technique.
AUTHOR CREDIT STATEMENT
Adriana Souza de Jesus: investigation, methodology,
writing - original draft; Cibele Braga de Oliveira:
conceptualization, writing - review & editing; Wilson
Humio Murata: resources; Selly Sayuri Suzuki: re-
sources, writing - review & editing; and Ary dos
Santos-Pinto: conceptualization, formal analysis, proj-
ect administration.
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