ORIGINAL ARTICLE

Factors related to microimplant-assisted

rapid palatal expansion in teenagers and
young adults: A cone-beam computed
tomography study
Fang Yi, Ou-Sheng Liu, Lei Lei, Si-Ling Liu, Yue Wang, Yan-Hao Chu, Ling-Ling Zhang, Cheng-Ri Li,
Jun-Jie Chen, and Yan-Qin Lu
Changsha, Hunan, China

Introduction: For patients with maxillary transverse deficiency, selecting an appropriate therapeutic method
is important for the treatment effect and prognosis. Our study aimed to explore factors related to
microimplant-assisted rapid palatal expansion (MARPE) in teenagers and young adults using cone-beam
computed tomography. Methods: Twenty-five patients who underwent MARPE were included in this retro-
spective study from February 2014 to June 2019. Midpalatal suture density (MPSD) ratio, midpalatal suture
maturation (MPSM), bone effect, dentoalveolar effect, and dental effect in maxillary first molar were evalu-
ated using cone-beam computed tomography. Spearman correlation analysis was used to analyze the
correlation between the MPSD ratio, MPSM, age, and the expansion amount generated by MARPE.
Results: Twenty-five patients (mean age, 19.84 6 3.96 years; range, 15-29 years) with maxillary transverse
deficiency were analyzed. Age was negatively correlated with bone expansion, alveolar expansion, and
alveolar change (all P \0.05). There was a negative correlation between MPSM and nasal cavity variation,
bone expansion, and alveolar change (all P \0.05). The bone expansion was negatively correlated with
MPSD ratio 3 (r 5 0.417; P \0.05) and MPSD ratio 4 (all P \0.05). Conclusions: Age, MPSM, and
MPSD ratio were significantly related to the MARPE effect. Age, MPSM, and MPSD ratio should be consid-
ered when choosing MARPE. (Am J Orthod Dentofacial Orthop 2023;163:475-82)

From the Hunan Key Laboratory of Oral Health Research and Hunan 3D Printing
Engineering Research Center of Oral Care and Hunan Clinical Research Center of
Oral Major Diseases and Oral Health and Xiangya Stomatological Hospital, and
Xiangya School of Stomatology, Central South University, Changsha, Hunan,
China.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
All procedures performed in studies involving human participants were in accor-
dance with the ethical standards of the institutional and/or national research
committee and with the 1964 Helsinki declaration and its later amendments or
comparable ethical standards. The study was approved by the Medical Ethics
Committee of Xiangya Stomatological Hospital, Central South University (no.
2014003).
This work was supported by the China Hunan Provincial Science and Technology
Department (no. 201974), Changsha Municipal Natural Science Foundation (no.
kq2014214), and Research Start-up Fund for Young Teachers of Xiangya Stoma-
tological Hospital, Central South University (No 2020YQ01).
Address correspondence to: Yan-Qin Lu, Department of Orthodontics, Xiangya
Stomatological Hospital, Central South University, No 72, Xiangya Rd, Kaifu Dis-
trict, Changsha, 410000 Hunan, China; e-mail, xiangyalyq@163.com.
Submitted, September 2021; revised and accepted, January 2022.
0889-5406
Ó 2022 by the American Association of Orthodontists. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/
by-nc-nd/4.0/).
https://doi.org/10.1016/j.ajodo.2022.01.013
M
axillary transverse deficiency is a common
malocclusion, with an occurrence rate of
21% and 10% in children and adults.1 It can
cause masticatory speech disorder and jaw function dis-
order and affect facial beauty.2 Rapid maxillary expan-
sion (RME) is a usual therapeutic method for
improving the transverse difference of maxillary narrow-
ing. However, for teenagers or adults with no growth po-
tential, ameliorating maxillary narrowing using
traditional RME is rarely successful and even harmful
as sutures begin to fuse and arch resistance increases.3
Therefore, most scholars suggest that RME should be
performed before puberty.1,4 Another method,
surgically-assisted rapid palatal expansion (SARPE), is
recommended for adult patients.5 However, because of
the limitations of SARPE, such as high cost, severe surgi-
cal trauma, and general anesthesia, most patients are
reluctant to receive this therapeutic method.6,7 In recent
years, microimplant-assisted rapid palatal expansion
(MARPE) has been used in teenagers and adults, which
reduces the risk of SARPE and the side effects of
475
476
traditional RME, such as eliminating unwanted dental
tipping.8 MARPE appliance is beneficial for adults with
more resistance to skeletal expansion.9 It has been re-
ported that the success rate of MARPE in adults was
about 84.2%-87.0%.8,10 However, if MARPE fails, the
treatment methods must be changed to SARPE, which
is more traumatic. In addition, the time point to shift
from MARPE to SARPE is not clear enough, especially
for young adults.11 Hence, it has great clinical signifi-
cance to determine the valid predictors of MARPE in
young people.
Midpalatal suture resistance is one of the main obsta-
cles to midpalatal expansion, and the increase in midpala-
tal suture fusion will reduce the possibility of successful
expansion.12 Because of the gradual fusion of midpalatal
sutures and other craniofacial sutures from adolescence to
adulthood, the risk of RME failure increased.13,14 Howev-
er, some studies have shown that the relationship between
the time of palatal suture fusion and age was not abso-
lute, such as patients aged 32-71 years can still have no
fusion.15,16 Therefore, it is speculated that age may not
be a reliable indicator of palatal suture fusion.
Angelieri et al17 has reported that the midpalatal suture
stage is a predictor of midpalatal suture maturation
(MPSM). Nevertheless, Gr€ unheid et al. denied the relation-
ship between the midpalatal suture stage and RME and
found a correlation between the midpalatal suture density
(MPSD) ratio and RME.18 Cone-beam computed tomog-
raphy (CBCT) has more advantages than traditional
2-dimensional imaging in orthodontic treatment, which
can clearly show the anatomic structure of the midpalate
suture by orienting axial slices without overlapping other
structures.19,20 This advantage allows an accurate evalua-
tion of MPSM, thus helping us to determine whether con-
ventional or surgically-assisted maxillary expansion is
more appropriate.21
This study aimed to ascertain factors related to
MARPE by analyzing the correlations between the age,
MPSM, MPSD ratio of different regions and bone effect,
dentoalveolar effect, and dental effects using CBCT in
patients without growth potential. It is expected to pro-
vide a basis for the orthodontic design of patients with
maxillary transverse deficiency.
MATERIAL AND METHODS
Patients who underwent MARPE from February 2014
to June 2019 were included in this retrospective study.
This study was approved by the ethics committees of
Xiangya Stomatological Hospital, and all patients or
guardians provided written informed consent.
Inclusion criteria were (1) patients with maxillary
transverse deficiency requiring bone expansion, (2)
April 2023  Vol 163  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Yi et al
patients with good oral hygiene and periodontal condi-
tion, and (3) teenagers and adults without growth po-
tential. The exclusion criteria were (1) patients with a
history of orthodontic therapy, maxillofacial trauma,
surgery, or respiratory therapy, (2) patients with systemic
disease or pathologic injury of the jaw bone, (3) patients
with maxillofacial deformities, such as cleft lip and pal-
ate; (4) patients who take long-term of drugs affecting
bone metabolism, such as glucocorticoids, antiepileptic
drugs, antituberculosis drugs, thyroid hormones, hepa-
rin, and so on; (5) patients cannot rotate the reamer
on time, and the implanted screw falls off repeatedly;
and (6) patients without preexpansion or postexpansion
imaging data.
The CBCT ProMax 3D device (Planmeca, Helsinki,
Finland) was set to capture images with 360 rotation
at the following settings: 10.0 mA, 96 kV, and a pulsed
scan time of 12 seconds. CBCT images obtained with a
voxel size of 0.3 mm, axial slice thickness of 0.3 mm,
and scanning area of 15 mm 3 15 mm. All patients
were positioned upright, seated, with their heads stabi-
lized against a headrest. During scanning, the patients
maintained the teeth in occlusal contact maximumly,
and their lips and tongues were relaxed without swal-
lowing. CBCT was performed by the same technician 3
months after the completion of the expansion.
Implant screws (length 3 diameter: 8 mm 3 1.4 mm
or 12 mm 3 1.6 mm; Vector TAS; Ormco, Glendora,
Calif) were implanted between the maxillary apex and
maxillary first premolars, the maxillary second premo-
lars, and the first premolars at the midpalatal margin
to the third part of the midpalatal suture. The 4 implant
screws should be placed in relatively parallel and, as far
as possible dispersed positions. After the operation, the
C-expander was employed (Fig 1, B). The patients were
asked to activate the expander every 2 days for an
expansion of 0.25 mm per time and continuously
expanded for 14 days until the expansion was achieved
to 7 mm. In addition, patients were asked to apply force
simultaneously, with an interval of 12 hours for each
extension.
Before CBCT, the head position shall be corrected to
standardize the measurement head position.22 Thus, the
expansion, MPSD ratio, and MPSM were measured.
Table I shows all measurement indexes were
measured on the basis of CBCT data and analyzed with
Dolphin 3D Imaging software (version 11.9; Dolphin Im-
aging and Management Solutions, Chatsworth, Calif).
All measurement indexes were measured 3 times before
and after arch expansion, and the average value of the 3
times was calculated.
The maxillary first molar was measured by Dolphin
Imaging software with molars as measurement plane
Yi et al 477

Fig 1. The expander and the position of microimplants: A, CBCT image of C-expander in place; B, The
position of implant screws and image of the expander

Planmeca Romexis Viewer) measured gray density

Table I. Definition of measurement index (thickness of 0.4 mm). A representative region of
Index Description 4 3 4 mm was selected for each indicator, each indicator
NLW Linear distance (mm) between the outermost was measured 3 times, and the average value was calcu-
points of the outer edge of the nasal cavity lated. According to the method described previously by
NF Linear distance (mm) that crosses crosswise Gr€unheid et al.18 Computed tomography data of the
through the base of the nasal cavity and is
midpalatal suture area, soft palate area, and midpalatal
tangent to it
MW Midpalatal width bone area were measured. The measurement indexes
HP A straight line transverse to the base of the hard are shown in Figure 3, B. The definitions of the measure-
palate and tangent to it, linear distance (mm) ment indexes are shown in Table II. The average gray
between the line and the left and right density values were used to calculate the MPSD ratio
intersection of the lateral margin of the maxilla
by the following equation: MPSD ratio 5 (GDs
HP 5 A line 5 mm under the hard palate parallel to the
nasal floor tangent GDsp)/(GDppm GDsp). The MPSD ratio could range
BC Linear distance (mm) between buccal tips of the from 0 to 1, with lower values indicating less calcifica-
same teeth on both sides tion and higher values indicating greater calcification.18
DBC The total expansion Gr€
unheid el al’s method was used to position the
DMW Bone expansion
plane by Planmeca Romexis Viewer software.18 The
DHP5-DMW Dentoalveolar expansion
DBC-DHP5 Dental expansion sagittal and coronal planes were adjusted so that the
DHP5 Dentoalveolar change cross-section passed through the center of the hard pal-
ate and was parallel to the hard palate (Fig 4). All mea-
NLW, nasal lateral width; NF, nasal floor; MW, midpalatal width;
HP, hard palate; HP5, 5 mm below the hard palate; BC, buccal cusp.
surements were made on a cross-section.
Palate suture images in CBCT were divided into
stages A-E by Angelieri et al.17 According to their
(Fig. 2). The expansion effect includes bone, dentoalveo- method, midpalatal sutures were staged before MARPE
lar, and dental effects and dentoalveolar change repre- and evaluated by an experienced orthodontist. The eval-
senting the difference of each index before and after uation criteria were reported in a previous study.
arch expansion.15
Statistical analysis
According to the midpalatal anatomy, the midpalatal
suture was divided into the anterior, middle, and poste- The sample size was estimated using a 2-sided paired
rior (Fig 3, A). CBCT random software (version 3.0.1.R; z-test, with an a level of 0.05, a 96% power, and a mean

American Journal of Orthodontics and Dentofacial Orthopedics April 2023  Vol 163  Issue 4
478 Yi et al

Fig 2. The reference plane for the expansion measurement. The coronal plane was located at the level
of bifurcation of the root of the homonymous tooth, adjusting the direction of the cross-section so that
the shape of the crown and palatal root could be seen completely in the coronal plane.

Fig 3. Midpalatal suture zone and bone density measurement site: A, Midpalatal suture division; B,
Measurement of MPSD in different areas.

of paired differences of 0.6 6 0.9. Considering these pa-
rameters, a sample size of at least 25 patients was neces-
sary. Intraexaminer reliability was assessed using
intraclass correlation coefficients, with a value .0.75
considered good reliability. All statistical analyses were
performed using SPSS (version 22.0; IBM, Armonk,
NY). Quantitative data were expressed as means 6 stan-
dard deviations. A t test was used for the data conform-
ing to the normal distribution, and a nonparametric test
was performed for the data not conforming to normal
distribution. Spearman correlation analysis was used to
analyze the correlation between arch expansion and
age, MPSM, and MPSD ratio. Statistical significance
was set at P \0.05.
RESULTS
A total of 25 patients (mean age, 19.84 6 3.96 years;
range, 15-29 years) with maxillary transverse deficiency
were enrolled in this retrospective study. Table III shows
the baseline characteristics for all patients, including 15
(60.0%) patients with MPSM stage C and 7 (28.0%) pa-
tients with MPSM stage D.

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Yi et al
Table II. Definition of MPSD ratio measurement index
Index Description
GDs Average gray density values for defined regions of the
suture
GDppm Average gray density values for defined regions of the
palatal process of the maxilla
GDsp Average gray density values for defined regions of the soft
palate
GDs0 Average gray density values for defined regions of the
midpalatal suture
GDs1 Average gray density values for defined regions of the
anterior midpalatal suture
GDs2 Average gray density values for anterior central segment
of midpalatal suture
GDs3 Average gray density values for posterior middle segment
of midpalatal suture
GDs4 Average gray density values for posterior midpalatal
suture
Intraclass correlation coefficient values of the mea-
surements (MW, NF, HP, HP5, BC, and NLW)
were .0.92, indicating excellent intraexaminer reli-
ability. As shown in Table IV, MW, NF, HP, HP5, BC, den-
toalveolar expansion, and dental expansion were
significantly increased after MARPE (all P \0.05), indi-
cating that the maxillary base bone was expanded after
MARPE.
Intraexaminer reliability was .0.75 for all of the gray
density value measurements. Spearman correlation
analysis (Table V) showed that MPSM were negatively
correlated with DNLW (r 5 0.409; P \0.05), DMW
(r 5 0.620; P \0.01), and DHP5 (r 5 0.469;
P \0.05). Age was negatively correlated with DMW
(Fig 5, A; r 5 0.495, P \0.05), DHP5 (Fig 5, B; r 5
0.696, P \0.01), and DHP5-DMW (Fig. 5, C; r 5
0.521, P \0.01). In addition, DMW were negatively
correlated with MPSD ratio 3 (Fig 5, D; r 5 0.417;
P \0.05) and MPSD ratio 4 (Fig 5 E; r 5 0.465;
P \0.05). In summary, MPSM, age, and MPSD ratio
were correlated to the expansion effect and might be
used as the estimated indexes of MARPE.
DISCUSSION
This study explored factors related to MARPE by
analyzing the correlations between the age, MPSM,
MPSD ratio of different regions and bone effect, den-
toalveolar effect, and dental effects using CBCT in pa-
tients without growth potential. The results revealed
that age, MPSM, and MPSD ratio were significantly
correlated with the MARPE effect.
MARPE is a microimplant implanted into the palatal
jackscrew to ensure expansion of the underlying basal
bone, minimizing dentoalveolar tipping and expansion.
American Journal of Orthodontics and Dentofacial Orthopedics
479
Although microimplants are not supposed to move in
bone, alveolar bending is inevitable with MARPE
because of the rotation of the 2 halves of the
maxilla.23,24 Lin et al25 also reported that the bone-
borne expanders (C-expander) produced buccal tipping
of the alveolar bone and crown expansion. Therefore,
the dental effects could still be observed in MARPE.
The fusion of the midpalatal suture presents obvious
variability with the age of the patient, and the degree of
fusion increases with age.17 However, more and more
research has demonstrated no direct correlation between
age and the time of palatal suture fusion. Patients aged
32, 54, and 71 years may still have unfused midpalatal
sutures.10,11,15 Histologic and computed tomography
have also shown that age is unreliable for palatal suture
fusion.11 Therefore, the actual age of patients is not a
characteristic indicator of true midpalatal maturity.26
Interestingly, our result showed a significant negative
correlation between DMW, DHP5, and DHP5-DMW
and age after MARPE. The arch expansion resistance
caused by other maxillary suture fusion increases with
age for adolescents or adults without growth poten-
tial.27 Thus, we speculate that this is the primary reason
for the discrepancy between the previous study and ours.
Based on previous studies and our results, we hypothe-
sized that age could be considered a contributing predic-
tor of MARPE outcome.
MPSM can also be used as a predictor of the MARPE
effect. Kukemeyer28 found that MPSM was negatively
correlated with midpalatal suture expansion. At the
same time, our study also confirmed the negative corre-
lation between MPSM and DMW, DHP5, and DNLW,
which verified Kukemeyer’s results. MPSD ratio refers
to the gray density value of the midpalatal suture to
the gray density of the hard lateral palate.24 The applica-
tion of the MPSD ratio is a robust clinical diagnostic
parameter of MARPE.29,30 Previous studies showed
that the mean MPSD ratio negatively correlated with
the maxillary extension width in patients receiving
RME treatment.18 Similarly, this study verified that
MPSD ratios (3 and 4) were negatively correlated with
bone expansion. However, this study found no link be-
tween the mean MPSD ratio and the amount of MARPE;
the MPSD ratio of the midposterior part and the poste-
rior part were negatively correlated with the changes in
the alveolar bone of MARPE. Because the midpalatal su-
ture fusion begins at the posterior part and fuses forward
from the posterior palatal bone to the maxilla along the
midpalatal suture10; therefore, there is a significant dif-
ference in the anterior and posterior MPSD ratio be-
tween adolescents without growth potential and adult
patients. According to Gr€ unheid et al,18 patients who
received RME treatment are still in the growth and
April 2023  Vol 163  Issue 4
480 Yi et al

Fig 4. The judgment plane of palatal suture staging. The sagittal and coronal planes were adjusted so
that the cross-section passed through the center of the hard palate and was parallel to the hard palate.

Table III. Baseline characteristics of patients Table IV. The changes in dilation amount after
Characteristics Patients (n 5 25)
MARPE
Gender, n (%) Dilation
Male 4 (16.0) amount Pretreatment Posttreatment DPost-Pre P value
Female 21 (84.0) MW (mm) 0.04 6 0.11 1.32 6 0.69 1.27 6 0.69 \0.001
Age (y), mean 6 SD (range) 19.84 6 3.96 (15.0-29.0) NF (mm) 65.60 6 5.96 67.32 6 6.22 1.72 6 1.42 \0.001
MPSD ratio, mean 6 SD (range) HP (mm) 63.86 6 5.64 65.67 6 5.85 1.81 6 1.23 \0.001
0 0.625 6 0.132 (0.362-0.861) HP 5 (mm) 60.40 6 4.34 62.32 6 4.40 1.92 6 1.16 \0.001
1 0.653 6 0.150 (0.320-0.929) BC (mm) 53.02 6 4.34 56.71 6 4.30 3.69 6 2.18 \0.001
2 0.710 6 0.128 (0.496-0.944) Dentoalveolar 0.63 6 0.86
3 0.571 6 0.170 (0.267-0.878) expansion
4 0.668 6 0.137 (0.316-0.870) Dental 1.70 6 2.05
MPSM stage, n (%) expansion
B 2 (8.0)
C 15 (60.0) MW, midpalatal width; NF, nasal floor; HP, hard palate; HP 5, 5 mm
D 7 (28.0) below the hard palate; BC, buccal cusp; Dentoalveolar expansion,
E 1 (4.0) DHP5-DMW (mm); Dental expansion, DBC-DHP5 (mm).

SD, standard deviation.

development stage (age 12.9 6 2.1 years). Most patients

have nonobvious midpalatal suture fusion with low bone
density of the anterior, middle, and posterior parts. Our
research showed a significant difference in bone mineral
density between the anterior, middle, and posterior
palatal sutures in patients with nongrowth (age 19.95
6 4.39 years). The posterior MPSD ratio is one of the
limiting factors of whether the palatal suture could be
expanded. Therefore, it is consistent with the growth
law to evaluate the MPSD ratio of microimplant-
assisted rapid palatal expansion along the long axis of
adolescent or adult patients without growth potential.
The MPSD ratio of the middle posterior and posterior
part can become a useful clinical predictor for of midpa-
latal suture maturity. It also can be used to determine
whether patients could receive routine RME treatment
and whether adolescent and adult patients without
growth potential could use the MARPE for maxillary
expansion, thereby reducing unnecessary surgically-
assisted maxillary expansion. Taken together, the
MPSD ratio with the midposterior and posterior parts
could be used as a mature predictor to forecast the effec-
tiveness of MARPE.
In conclusion, age, MPSM, and the MPSD ratio with
the midposterior and posterior parts might be used to
predict the effectiveness of MARPE expansion.
AUTHOR CREDIT STATEMENT
Fang Yi contributed to conception and design, mate-
rials and samples, data collection and collation, and data
analysis and interpretation; Ou-Sheng Liu contributed
to project administration; Lei Lei contributed to mate-
rials and samples; Si-Ling Liu contributed to materials
and samples; Yue Wang contributed to materials and
samples; Yan-Hao Chu contributed to data analysis

April 2023  Vol 163  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Yi et al 481

Table V. The correlation between MPSM, age, MPSD ratio, and arch expansion
Index DNLW DMW DHP5 DHP5-DMW DBC-DHP5 DBC
MPSM 0.409* 0.620** 0.469* 0.038 0.220 0.093
Age 0.248 0.495* 0.696** 0.521** 0.055 0.401
MPSD ratio 0 0.064 0.209 0.094 0.109 0.020 0.021
MPSD ratio 1 0.178 0.257 0.348 0.207 0.115 0.225
MPSD ratio 2 0.010 0.126 0.085 0.001 0.075 0.039
MPSD ratio 3 0.039 0.417* 0.108 0.212 0.102 0.077
MPSD ratio 4 0.158 0.465* 0.077 0.188 0.013 0.051

DNLW, nasal cavity variation; DMW, bone expansion; DHP5-DMW, dentoalveolar expansion; DBC-DHP5, dental expansion; DBC, total expan-
sion; DHP5, dentoalveolar change.
*P \0.05; **P \0.01; ***P \0.001.

Fig 5. Correlations between the arch expansion and age and MPSD ratio. Best-fit lines are shown on
each plot with the least-squares linear regression equation.

and interpretation; Ling-Ling Zhang contributed to data
analysis and interpretation; Cheng-Ri Li contributed to
data analysis and interpretation; Jun-Jie Chen contrib-
uted to data collection and collation; and Yan-Qin Lu
contributed to conception and design.
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