special article

Non-surgical treatment of transverse deficiency in adults

using Microimplant-assisted Rapid Palatal Expansion (MARPE)
Daniel Paludo Brunetto1, Eduardo Franzzotti Sant’Anna2, Andre Wilson Machado3, Won Moon4

DOI: http://dx.doi.org/10.1590/2177-6709.22.1.110-125.sar

Introduction: Maxillary transverse deficiency is a highly prevalent malocclusion present in all age groups, from primary to permanent denti-
tion. If not treated on time, it can aggravate and evolve to a more complex malocclusion, hindering facial growth and development. Aside from
the occlusal consequences, the deficiency can bring about serious respiratory problems as well, due to the consequent nasal constriction usually
associated. In growing patients, this condition can be easily handled with a conventional rapid palatal expansion. However, mature patients
are frequently subjected to a more invasive procedure, the surgically-assisted rapid palatal expansion (SARPE). More recently, researches have
demonstrated that it is possible to expand the maxilla in grown patients without performing osteotomies, but using microimplants anchorage
instead. This novel technique is called microimplant-assisted rapid palatal expansion (MARPE). Objective: The aim of the present article was to
demonstrate and discuss a MARPE technique developed by Dr. Won Moon and colleagues at University of California – Los Angeles (UCLA).
Methods: All laboratory and clinical steps needed for its correct execution are thoroughly described. For better comprehension, a mature patient
case is reported, detailing all the treatment progress and results obtained. Conclusion: It was concluded that the demonstrated technique could
be an interesting alternative to SARPE in the majority of non-growing patients with maxillary transverse deficiency. The present patient showed
important occlusal and respiratory benefits following the procedure, without requiring any surgical intervention.

Keywords: Microimplant-assisted Rapid Palatal Expansion. Palatal expansion technique. Polysomnography. Obstructive Sleep Apnea Syn-
drome. Adult patients. Maxillary transverse deficiency. Posterior crossbite.

Introdução: a deficiência transversa da maxila é uma má oclusão com alta prevalência em todas as faixas etárias, da dentição decídua à perma-
nente. Se não for corrigida, pode agravar-se com o passar do tempo, prejudicando o crescimento e desenvolvimento facial. Além dos prejuízos
oclusais, essa deficiência pode trazer problemas respiratórios também severos, devido à consequente constrição da cavidade nasal. Em pacientes
em crescimento, a sua resolução é relativamente simples, por meio da expansão rápida convencional da maxila. Porém, os pacientes já maduros
geralmente são encaminhados para um procedimento mais invasivo, a expansão rápida de maxila assistida cirurgicamente (SARPE). Mais recen-
temente, pesquisadores têm demonstrado que é possível executar a expansão palatal esquelética em pacientes adultos sem auxílio de osteotomias,
mas sim com auxílio de mini-implantes. Essa técnica é denominada Microimplant-Assisted Rapid Palatal Expansion, ou MARPE. Objetivo: o
objetivo do presente artigo é demonstrar e discutir uma das técnicas disponíveis de MARPE, desenvolvida por Won Moon e colaboradores,
na University of California, Los Angeles (UCLA). Métodos: a técnica encontra-se detalhadamente descrita, com as etapas laboratoriais e clínicas
que devem ser seguidas para sua correta execução. Para descrevê-la, é apresentado o caso clínico de uma paciente adulta, detalhando toda a se-
quência do tratamento e os resultados obtidos. Conclusão: a técnica apresentada pode ser uma alternativa não invasiva à SARPE na resolução
da deficiência transversa de maxila, podendo ser empregada na maioria dos pacientes com crescimento facial finalizado. A paciente apresentada
demonstrou benefícios significativos nos aspectos oclusal e respiratório, sem a necessidade de intervenção cirúrgica.

Palavras-chave: Expansão rápida da maxila assistida por mini-implantes. Técnica de expansão palatina. Polissonografia. Síndrome da apneia
obstrutiva do sono. Pacientes adultos. Deficiência transversa de maxila. Mordida cruzada posterior.

How to cite this article: Brunetto DP, Sant’Anna EF, Machado AW,
1
Post-graduation Professor of Orthodontics, Universidade Federal do Paraná, Moon  W. Non-surgical treatment of transverse deficiency in adults using
Dental School, Department of Restorative Dentistry, Curitiba/PR, Brazil. Microimplant-assisted Rapid Palatal Expansion (MARPE). Dental Press J
2
A ssociate Professor, Universidade Federal do Rio de Janeiro, Dental School, Orthod. 2017 Jan-Feb;22(1):110-25.
Department of Pediatric Dentistry and Orthodontics, Rio de Janeiro/RJ, DOI: http://dx.doi.org/10.1590/2176-9451.22.1.110-125.sar
Brazil.
3
Adjunct Professor, Universidade Federal da Bahia, Dental School, Submitted: September 06, 2016
Department of Orthodontics, Salvador/BA, Brazil. Revised and accepted: October 10, 2016
4
A ssociate Professor, University of California, Los Angeles, Dental School,
Orthodontics Area, Los Angeles/CA, EUA.
» The authors report no commercial, proprietary or financial interest in the products
Contact address: Daniel Paludo Brunetto or companies described in this article.
Av. Sete de Setembro 4456, Curitiba/PR, Brasil – CEP: 80.250-210
E-mail: daniel_brunetto@hotmail » Patients displayed in this article previously approved the use of their facial and in-
traoral photographs.

© 2017 Dental Press Journal of Orthodontics 110 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

INTRODUCTION id palatal expansion (RPE) immediately, while still

The prevalence of transverse maxillary deficiency, growing. This procedure has been used for over a
which affects an important number of patients seek- century in orthodontics, and its positive effects have
ing orthodontic care, may reach 23.3% within the pri- been widely described and documented.12-15 The ear-
mary dentition population.1 This type of malocclusion lier the treatment is delivered, the better the prog-
usually develops during facial growth and development nosis and the outcomes, increasing chances of mor-
and, if left untreated, will probably affect the perma- phological and functional correction and bringing
nent dentition, since the chances of spontaneous cor- about proper facial development. During primary and
rection are low. Some of the most prevalent factors on mixed dentition and the first years of permanent den-
its multifactorial etiology are myofunctional disorders tition, RPE is a simple procedure with high success
of the stomatognathic system, usually associated with rates. A recent review of the literature showed that
deleterious habits such as thumb sucking.2,3 In these it is a stable procedure in the short and long term,
cases, the tongue may be in an abnormally lower po- regardless of the type of expander used.16
sition, which leaves room for the antagonist muscles Patient growth leads to progressive calcification and
(buccinators) to apply dominant forces and conse- interdigitation of craniofacial sutures, including the
quently constrict the maxillary arch. Intramembranous midpalatal suture, and RPE becomes more difficult
maxillary bone formation may be affected by and de- as facial growth approaches its completion because of
pends on surrounding muscles activity and individual increased mechanical resistance of these structures.17,18
breathing pattern along development.4,5 The amount of undesired orthodontic movement
At the same time, genetic and hereditary factors (buccal tipping of anchor teeth) and its side effects are
may determine the development of maxillary trans- proportional to patient age and skeletal maturation.
verse deficiencies. Typical cases are those of patients Therefore, adolescents tend to have greater tooth in-
with Class III malocclusion with mandibular progna- clination and buccal bone dehiscence and, therefore,
thism, in which P561T polymorphism in the GHR less orthopedic expansion than children.19,20
candidate gene, responsible for growth hormone The procedure becomes even more complex for
receptors, for instance, determines the excessive young adults. Although retrospective case series have
growth on condylar cartilage.6 As a result, maxillary demonstrated the success of tooth-borne expan-
and mandibular posterior teeth may present with in- sion in this age group,21,22 no well-designed clinical
creased overjet as the mandible is protruded (Fig 1). trials have determined its success rate. This treat-
If not properly managed within appropriate time, ment, therefore, may be classified as unpredictable
maxillary transverse deficiency, associated or not with and of high biological risk. A higher rate of side ef-
posterior crossbite, may result in several problems for fects, such as a reduction in alveolar bone thickness
the patient: different degrees of occlusal disharmony; and height, bone dehiscence and gingival recession,
changes in tongue posture; damage to periodontal may be expected as a result of important mechanical
structures, such as local bone loss and gingival reces- forces delivered at the teeth and its supporting struc-
sion; functional shift of the mandible due to incor- tures. Therefore, surgically-assisted rapid palatal ex-
rect buccolingual tipping of posterior teeth; asym- pansion (SARPE) is often indicated to these patients.
metric mandibular position in growing patients; joint This  procedure increases expansion predictability
disorders and muscle function disturbances; lack of and success, and reduces its side effects.23 One of the
space in the arch for adequate dental alignment.7,8,9 available SARPE techniques consists of a LeFort  I
The  most serious consequence of maxillary trans- osteotomy associated with surgical rupture of the
verse deficiency, however, might be the consequent midpalatal suture, which decrease the mechanical re-
narrowing of the nasal cavity, which increases nasal sistance to the lateral forces that will be applied by
air resistance (Fig 2) and may be an etiological factor Hyrax expanders, usually anchored to the first mo-
of obstructive sleep apnea syndrome (OSAS).10,11 lars and first premolars. However, despite its benefits,
For the treatment of this condition, according to SARPE increases biological and financial costs of the
orthodontic consensus, patients should undergo rap- treatment. The surgery requires hospitalization and

© 2017 Dental Press Journal of Orthodontics 111 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

general anesthesia, which might scare patients away

from surgical-orthodontic treatment for good.21
In face of that, some authors have investigated the
use of orthodontic microimplants as auxiliary anchor-
age devices to optimize the application of mechanical
forces to circummaxillary sutures, thus avoiding the
otherwise indispensable osteotomies.24 This system,
which has been called microimplant-assisted rapid
palatal expansion (MARPE), applies forces to the mi-
croimplants, and not to the teeth or periodontium.
Different appliance designs and techniques have been
described in the literature, and each leads to specific
associated outcomes. A recent clinical study using
Figure 1 - Lateral radiograph and coronal CBCT slice of a patient with true
mandibular prognathism and excessive vertical growth; images show bilat-
one of them found an 86.96% success rate in young
eral skeletal posterior crossbite due to mandibular anterior position and lower adult patients (mean age = 20.9 ± 2.9 years), with sta-
tongue posture.
ble results after 30 months of follow-up.25
The objective of the present study was to describe
one of the techniques available for rapid palatal expan-
sion of non-growing patients, Maxillary Skeletal Expan-
sion (MSE), developed and improved along several years
by Dr. Won Moon and colleagues at the University of
California – Los Angeles (UCLA). For didactic reasons,
this article has been divided into the following sections:
introduction; laboratory and clinical procedures, dem-
onstrating the step-by-step manufacture and appliance
delivery; case report, to illustrate some of the technique
applications; discussion; and conclusion.

LABORATORY AND CLINICAL PROCEDURES

The laboratory manufacture of the MSE appliance
is similar to that of a conventional Hyrax expander.
The steps below should be followed:
» First visit: Thorough explanation of procedures
to the patient, clarifying all details and technical limi-
tations and reasserting that failure may occur; place-
ment of separator elastics on the permanent maxillary
first molars.
» Second visit: Removal of separators, prophylaxis
and band placement on first molars; conventional al-
ginate transfer impression; regular plaster pouring;
separators elastics placed again on molars; orthodon-
tic accessories (tubes and brackets) may be soldered to
the bands at this stage.
» Laboratory procedures (Fig 3): Selection of 8, 10
Figure 2 - Coronal slice shows maxillary transverse deficiency and, con- or 12 mm MSE, according to palate width (details be-
sequently, nasal cavity narrowing in adult mouth-breather with moder-
ate OSAS (AHI = 15.9). Are also noticeable the high-arched palate, low low); bending wires to reach the bands, following pal-
tongue position and anatomic disorders of nasal cavity (turbinate hyper-
trophy and septal deviation). ate curvature, at a separation of at least 2 mm along all

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Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

their extension; wire soldering to the bands, followed by the force is applied too far from the implant/bone in-
finishing and polishing; reverse traction hooks may be terface (Fig 5). The body of the expander should be
soldered to the buccal aspect of bands at this stage. placed as posterior as possible, close to the junction
» Third visit (Fig 4): Removal of separators, pro- of hard and soft palate (hard palate mucosa is whiter).
phylaxis and expander proof; application of topical The greatest resistance against suture opening is lo-
anesthetics to the palate; appliance cementing, check- cated in the sutures between maxilla and pterygoid
ing the vertical position in relation to palate; local in- plates (Fig 6), and forces should be applied more pos-
filtrative anesthesia; self-drilling microimplant place- teriorly to overcome initial resistance and promote
ment using appropriate digital key (Biomaterials Ko- parallel opening of the midpalatal suture (Fig  7).
rea®, Seoul, South Korea); immediate expander acti- When forces are applied directly into the center of
vation (2 to 3 turns); instructions about hygiene and resistance of the maxilla by means of MI, and not to
activation; prescription of analgesic drug of choice for teeth (as in conventional expansion), the force system
two days (optional); no need for antibiotic coverage if is more favorable due to a homogeneous force dissi-
the patient has good general health. pation,26 which prevents buccal tipping and produces
» Follow-up: The patient should be seen more a more parallel suture opening (Fig 8).27
often than in conventional expansion. In some cas- A small amount of anesthetics (no more than 1/4
es, the patient is not able to activate the expander at of a cartridge) may be applied only once on each side,
home due to increased resistance, and the profes- between the two ipsilateral MI. Anesthetic applica-
sional support is necessary. At all visits, the distance tion local should be carefully chosen, and the needle
of the expander from the mucosa should be checked. should always be placed close to the midpalatal suture
In case of contact, tissue inflammation develops rap- to avoid contact with the palatine artery. The opera-
idly compromising appliance removal. The stability tor should have extensive knowledge of the position
of all MI should be checked regularly using tweezers of this artery, which may vary according to palate
and, in case any mobility is found, MI should be re- depth.28 Whenever possible, a vasoconstrictor com-
moved; the treatment may continue, although extra- bined with the anesthetic should be used to reduce
carefully, even if there is only one MI on each side.25 bleeding, which is often absent.
» Removal: For removal, the same connector used MI should be placed carefully, although the guides
for placement, coupled with the digital key, should be (expander holes) facilitates its placement. MI should
slowly turned counterclockwise. Plaque may accumu- be as perpendicular as possible to the palatal bone
late on the MI head, which hinders MI gripping (care- (each MI parallel to all others) so that the force dis-
ful previous cleaning of the site is required). Due to the tribution is effective. Therefore, both the anteropos-
forces applied, MI tipping may occur and complicate the terior and the lateral inclination should be repeatedly
gripping. In most cases, the MI may be removed with- checked during placement. When placing the poste-
out anesthesia. Immediately after each MI is removed, rior MI, patient should keep the mouth wide open
a cotton pellet soaked in hydrogen peroxide might be to avoid changing their anteroposterior inclination
applied to the site to promote asepsis, but no additional (MI  tend to distal tipping). MI can be delivered in
care is required. Mucosa wounds usually heal in two to most patients without previous bone perforation, us-
three days after removal. MI should be discarded after ing the digital key. If torque is excessively high, bone
removal, and should never be sterilized or reused. perforation can be made using a 1 mm diameter drill.
The selected expander should be the one with A very high-arched and deep palate, typical of
the greatest expansion capacity that, at the same chronic mouth-breathers, may hinder the vertical
time, may be kept at an ideal vertical distance from positioning of the MSE. For these patients, the an-
the palatal mucosa. Bicortical anchorage (oral and terior or posterior segments of the expander can be
nasal) is determinant of success and if the expander trimmed so that the expander can be placed closer to
is too distant from the mucosa (more than 2 mm), the mucosa (Fig 9). This option is acceptable because
microimplants may not reach the nasal cortical bone. forces are applied to the MI, leaving to teeth only a
Moreover, chances of MI deformation are higher if supporting purpose during MI placement.

© 2017 Dental Press Journal of Orthodontics 113 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

Figure 3 - Laboratory procedures: midline (pala-

tal raphe) and limit between soft and hard palate
(clinically determined) traced using lead pencil
on model; selection of MSE with greatest expan-
sion capacity (8, 10 or 12 mm) that can be placed
flush to palatal mucosa; appliance wire segments
bended to outline palate curvature, holding at least
a 2 mm gap from the mucosa; expander should be
centralized to palatal raphe and placed at the most
posterior position possible, slightly before limit be-
tween soft and hard palate; soldering of wire seg-
ments onto the bands, followed by polishing; pos-
terior view shows that expander is flush to palatal
mucosa, but should not touch it.

Figure 4 - Clinical visit: Expander clinical proof,

topical anesthesia applied, and expander cement-
ed; after expander is cemented (as shown on plas-
ter model, for teaching purposes), infiltrative anes-
thesia is applied close to orifices of MI; after region
is anesthetized, MI are placed paying special at-
tention to anteroposterior and lateral inclination.
Most cases do not need previous perforation. In-
dex finger of one hand should hold the digital key,
and index and thumb of other hand firmly moves
key counterclockwise. During posterior MI place-
ment, patient mouth should be wide open to en-
sure correct anteroposterior inclination. MI should
touch expander gently and not push it toward the
mucosa. After the four MI are placed, initial stabil-
ity is tested using clinical tweezers. After confirma-
tion, expander is activated two to three times.

Although there are no randomized clinical trials, the ideal  protocol. The authors recommend giving the patient
following activation protocol is suggested as a reference, a paper form to control activations. The 8 mm MSE has 40
based on a sample of over 100 patients seen over 15 years activations (0.2 mm per turn); the 10 mm one, 50 activa-
(Table 1). In adults, activation may be reduced to once a day tions; and the 12 mm one, 60 activations. Activations should
after interincisor space appears. Patient’s biotype and treat- not reach the limit, because the expander loses rigidity as it
ment objectives should be regarded when determining the approaches the limit and might undergo some deformation.

© 2017 Dental Press Journal of Orthodontics 114 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

A B

Figure 5 - Force application too far from bone/mi- Figure 6 - Dry skull shows relation between the pterygoid plates of sphenoid bone and maxilla. These
croimplant interface, resulting in MI deformation. structures provide great resistance to lateral forces applied by the expander, and connection between
them has to be split apart for real skeletal expansion.

A B

Figure 7 - When expander is placed at a more posterior position, forces concentrate closer to the pterygoid plates, structures that offer great resistance to palatal
expansion. Therefore, occurs a parallel opening of the palatine suture anteroposteriorly and vertically, differently from conventional expansion, in which opening
takes the form of a "V" (broader in anterior region).

A B

Figure 8 - A) In conventional palatal expansion, forces are applied to teeth, below the center of resistance of the maxilla. This system of forces generates buccal
dentoalveolar tipping and an inverted-V opening (coronal view), indicated by the red dotted lines. The amount of momentum generated is directly associated
with palatal depth. B) in MARPE, forces are applied directly into the maxillary center of resistance by means of the MI, which practically eliminates inclination
forces of posterior teeth and promotes more parallel suture opening in a coronal view (indicated by red dotted lines).

© 2017 Dental Press Journal of Orthodontics 115 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

Table 1 - Suggested activation protocol.

CASE REPORT
A 22-year and 6-month-old female was seen for AGE GROUP ACTIVATION

orthodontic treatment at the Orthodontic Clinic of Beginning of adolescence 3 to 4x/week

the Universidade Federal do Paraná, Brazil. Her chief End of adolescence 1x/day
Young adults 2x/day
complaint was posterior crossbite and deficient
Older than 25 years 2x or +/day
breathing, especially during sleep. The patient had
not undergone any orthodontic treatment before, but
had already made up her mind to avoid maxillary ex-
pansion surgery.
Facial examination revealed a harmonic profile and
proportional facial thirds. The smiling photo showed
excessive buccal corridor display and easily noticeable
transverse maxillary deficiency (Fig 10). The  man-
dibular arch had moderate anterior and posterior
crowding and left transverse asymmetry due to the
posterior crossbite on that side. In the maxillary arch,
there was mild crowding and transverse asymmetry
(opposite to the mandibular arch) on the left side as
well, due to the same crossbite (Fig 11). It  was  also
found microdontic maxillary lateral incisors and
right maxillary midline shift. Right molars and ca- Figure 9 - Maxillary occlusal photograph showing removal of anterior wire seg-
nines displayed a Class I relationship, bearing nor- ments of MSE, to improve vertical fit in a very narrow and high-arched palate.

mal horizontal and vertical overjet. On the left side,

canines had an edge-to-edge relationship (Class II),
with posterior crossbite (Fig 12). Lateral radiograph
showed a good skeletal relationship, as well as good spiratory disorder, reported by the patient herself at
inclination and position of maxillary and mandibu- first, and later confirmed by the polysomnography.
lar incisors (Fig 13). A coronal CBCT slice revealed Treatment alternative consisted of fixed orthodontic
exacerbated inclination of teeth (torque) in posteri- appliance and microimplants for intrusion and buc-
or crossbite (Fig 14). Sagittal slices of the joints re- cal inclination of the left maxillary posterior teeth to
vealed that the condyles were not centrally positioned compensate the buccolingual inclination of teeth in
in the fossa, which confirmed the clinically present crossbite area, with possible future side effects on its
double-bite (Fig 15). Because of her breathing com- supporting structures.
plaints, it was applied the Epworth Sleepiness Scale Treatment started with the placement of a 10 mm
and Quebec Sleep Questionnaire as screening tools, maxillary skeletal expander (MSE) and three imme-
which revealed a high risk of obstructive sleep apnea diate activations (1/4 of a turn, 90 degrees each), fol-
syndrome (OSAS). Therefore, the patient underwent lowed by two daily activations. By the second week,
in-home polysomnography (Nox Medical, Reykja- the patient reported having heard clicks in the region
vik, Iceland), and results revealed an apnea/hypopnea of the palatal suture and, in the following days, ap-
index (AHI) of 7.9, classified as mild apnea syndrome pearance of the interincisal diastema (Fig 17). There
according to the American Association of Sleep Med- was a discrete opening of the anterior bite due to con-
icine guideline,29 associated with moderate snoring tact of the buccal cuspid of the left first maxillary mo-
and isolated episodes of bruxism (Fig 16). lar, which moved in the direction of overlapping the
The first treatment option was non-surgical antagonist mandibular molar. Photographs after 34
rapid palatal expansion (MARPE) because the pa- activations confirmed suture opening and lack of col-
tient refused to have SARPE. We thought skeletal lateral buccal inclination of maxillary molars (Fig 18).
expansion was necessary because of the patient’s re- The patient often needed help to perform the activa-

© 2017 Dental Press Journal of Orthodontics 116 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

Figure 10 - Initial facial photographs: harmonic profile and proportional face thirds. Smiling photo shows excessive buccal corridors, particularly on left side.

Figure 11 - Initial occlusal photographs; moderate

crowding in mandibular arch due to constriction
caused by the maxilla. Note the lingual inclination
of left posterior teeth in maxillary arch.

Figure 12 - Initial intraoral photographs: good occlusal relationship on the right side and edge-to-edge relationship of left canines (Class II); left superior buccal
segment in crossbite.

tion because of increased mechanical resistance. Af- for two reasons: circummaxillary sutures had already
ter 44 activations, at a total of 8.8 mm screw open- been mobilized, and, therefore, skeletal gains should
ing, the MSE was removed for the placement of an- be preserved; and we would like to ensure buccal in-
other expander, a common practice depending on clination of maxillary left posterior teeth to optimize
case severity. At this time, crossbite was still present future orthodontic treatment. At this point, the pa-
(Fig 19). However, instead of using another MSE and tient had already reported important improvement
continuing with pure skeletal expansion, we decided of sleep quality, with facilitated nose breathing and
to place a conventional tooth-borne Hyrax expander reduction of rhinitis episodes, frequent in the past.

© 2017 Dental Press Journal of Orthodontics 117 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

Figure 13 - Lateral radiograph obtained from Figure 14 - Coronal CBCT slice at the level of Figure 15 - Sagittal slice shows incorrect posi-
CBCT shows harmonic maxillomandibular skele- maxillary first molars shows excessive palatal in- tion of condyles into articular fossa, especially
tal relationship and satisfactory position of maxil- clination of these teeth; tongue is at a low posi- on the right side (contralateral to the posterior
lary and mandibular incisors: note that mandibu- tion; measurement indicated maxillary constric- crossbite).
lar ramus heights are asymmetric. tion and, consequently, nasal cavity constriction.

Figure 16 - Baseline in-home polysomnography

shows an AHI of 7.9, defined as mild OSAS; de-
spite that, patient has good oxygen saturation
along the night.

An 8.8 mm expansion at the palatal suture may be As unilateral expansion is not feasible, it was neces-
classified as substantial, as mean opening in conven- sary to overcorrect the right side until there was buc-
tional expansion in growing patients is usually around cal crossbite, so that the ideal inclination was achieved
4 to 5 mm. in the opposite side (Fig 20). Activations continued
On the same day the MSE was removed, to elimi- until the total expansion was 7 mm, when the ex-
nate any possibility of relapse, an 11 mm Hyrax ex- pander was tied-out (Fig 21).
pander was delivered. The bands were placed onto Facial photographs after expansion showed de-
the first molar, and a palatal wire extended to the first creased buccal corridor display and correction of
premolar on both sides. We continued the protocol of the lower midline shift at centric occlusion, which
two daily activations until the desired inclination of confirmed that the mandible was in fact deviated at
the left maxillary posterior teeth was achieved. The in- maximum intercuspation before expansion (Fig 22).
crease of interdental diastema was clear during the Post-expansion CT scan confirmed the opening of
activation period, confirming the skeletal   changes. the palatal suture (Fig 23) and also showed a more

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Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

A B

Figure 17 - Photograph taken after 20 activations (4 mm); interincisal diastema confirms suture opening. Figure 18 - Maxillary occlusal photograph taken
Discrete anterior open bite appears due to an overjet reduction of the posterior teeth in crossbite, which after 34 activations (6.8 mm). Absence of tooth
generates premature occlusal contacts. or alveolar bone tipping as left posterior teeth still
show palatal inclination.

mandibular arch to alleviate the crowding has a bet-

ter relapse prognosis, because the maxillary arch was
skeletally expanded with MARPE creating overjet for
lower intercanine width increase. When  the Hyrax
expander is to be removed, teeth that were overcor-
rected during expansion on the right side will natu-
rally return to the ideal position, due to muscular ac-
tivity. After the bones are placed in a favorable trans-
verse position, the case became simple to solve using
corrective orthodontic treatment and Class II elastics
Figure 19 - Photograph taken during MSE removal, after 44 activations on the left side. Any other treatment alternative, even
(8.8 mm); high mechanical resistance bent expander built-in support wires;
MI with no deformation when removed are signs of ideal progression of the using the most sophisticated biomechanics, would be
expansion.
challenged by the lower midline deviation. Even so,
the treatment time would be increased and the con-
dyles would remain in an unfavorable position.
favorable buccolingual inclination of the left poste- Another promising application of this technique
rior teeth and an increase on the nasal cavity floor may be for Class II hyperdivergent patients, who
(Fig 24). However, the greatest treatment benefit was often present with maxillary transverse deficiency.
probably the one revealed by post-expansion poly- According to Buschang et al,31,32 the best treatment
somnography: a reduction of the AHI from 7.9 to 1.5. in these cases is true mandibular counter-clockwise
There was also a substantial improvement of clinical rotation. Using MARPE, intrusion of maxillary
symptoms (Fig 25). It is important to inform that no molars may be executed immediately after maxillary
other concurrent therapy for the breathing issue was expansion, which promotes counterclockwise rota-
delivered and that the patient’s body mass index re- tion of the mandible improving the sagittal relation-
mained the same throughout the treatment. ship. For that purpose, it is enough to remove the
The Hyrax expander would be held in place for bars that hold the expander to the bands after the ex-
the next four months to achieve satisfactory suture os- pansion active retention period. The expander itself
sification. After 3 months of inferior fixed appliance will promote transverse retention while it is used for
therapy, the inclination of posterior teeth was very skeletal anchorage to promote posterior maxillary
improved and almost all the crowding was solved, intrusion. In such cases, MI should also be placed in
helping to close the anterior bite back to its baseline the mandibular arch to avoid compensatory extru-
status. We believe that the expansion made on the sion of the antagonist teeth.

© 2017 Dental Press Journal of Orthodontics 119 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

Figure 20 - Intraoral photographs after expansion. Spaces created by the expansion were distributed along maxillary arch. When manipulated to centric occlu-
sion, a substantial transverse increase was evident and the posterior crossbite corrected. Following the expander removal after the recommended retention time,
right posterior teeth will return to their adequate inclination. A broader maxillary arch allows for the expansion of mandibular arch, which was also constricted.

Figure 22 - Facial photographs after expansion.

Improved mandibular position and buccal corri-
Figure 21 - Occlusal photo taken at Hyrax tie- dors as a result of skeletal and dental expansion
lace; smaller expansion on left side, limited by promoted by the two expanders.
crossbite occluding forces. Left posterior teeth
aligned to canine and second molar, which re-
duces time of treatment with fixed appliance.

Figure 23 - CBCT slices show homogenous suture opening along anterior and posterior regions and uniform separation of the hemimaxillae.

DISCUSSION which grow toward each other until they are mechani-
Embryologic formation and development of the cally interlocked, progress along the following post-
midpalatal suture are thoroughly described in the lit- natal development stages: synfibrosis, broad distance
erature, particularly in histological studies of human between parallel borders; synarthrosis, narrower sinu-
specimens.33 Medial borders of the hemimaxillae, ous course; synostosis, complete interdigitation.34

© 2017 Dental Press Journal of Orthodontics 120 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

Figure 24 - Coronal slice after expansion shows more favorable buccolin-

gual inclination (torque) of posterior maxillary teeth. Also, nasal cavity floor
is 23.2  mm wide, larger than at baseline (15 mm). Wax-bite registration was
sent to the radiologic laboratory, but the CBCT scan was obtained at maximal
intercuspation, suggesting that posterior left crossbite is still present. There
was no reason to irradiate the patient again.

Figure 25 - Post-expansion in-home polysom-

nography depicted an AHI of 1.5, a substantial
reduction from baseline value of 7.9. Patient pre-
sented a more homogeneous breathing pattern
during sleep. Clinical symptoms have also im-
proved significantly.

Figure 26 - Photographs three months after infe-

rior fixed appliance delivery. Note anterior overbite
improvement, matching of the dental midlines and
almost complete crowding dissolution.

© 2017 Dental Press Journal of Orthodontics 121 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

Figure 27 - The overjet created on the left cuspids will allow for an increase
on the intercanine distance in the mandibular arch, completing its ideal align-
ment. On the right side, the upper cuspid will also present with some overjet
when its torque is corrected.

However, the age at full suture ossification (synos- ies of conventional palatal expansion in young adults
tosis) has not been definitely determined in the lit- without MI have warned about the risk of side ef-
erature. Recent histological studies revealed that only fects.23,39 Lin et al40 recently conducted a direct com-
the anterior third of the suture was ossified in human parison of MARPE and conventional expansion
beings older than 70 years, although ossification ap- (mean age 18.1 ± 4.4 years) and found that MARPE
peared complete on radiographs.35 In those samples, was more orthopedically efficient and had a lower rate
connective tissue was still found in the posterior re- of dentoalveolar side effects. This initial data may be
gions. Such studies support the theory that the mid- suggestive of evidence, which should be further in-
palatal suture may be the only cranial suture that does vestigated in randomized clinical trials. Moreover,
not achieve full ossification because of the constant the effect of MARPE is basically orthopedic, because
mechanical stress that is applied to it.35,36 Histologi- forces are applied directly to the bone; therefore,
cal studies have demonstrated that caution should be there is no need of overcorrection. In conventional
taken when defining the stage of ossification using expansion, however, overcorrection is recommended
imaging exams.35,37 because of the orthodontic effects (buccal tipping),
Occlusal radiographs or CBCT should be request- which may often lead to relapse.19,41 According to
ed to confirm MARPE success, defined by midpalatal Haas,14 midpalatal suture rupture takes place after the
suture opening, because not all cases display an in- third or fourth complete turn, at a screw opening of
terincisal diastema. However, if the diastema is creat- about 3 to 4 mm, because of tooth inclination. When
ed, as in the case here reported, suture split and skel- using MARPE, suture split happens sooner, usually
etal expansion of the maxilla are evident. It remains still in the second week of activation, because there is
unclear why few MARPE cases fail, but it is believed less tooth tipping.
that differences in calcification patterns of the mid- A new MSE has been recently developed to in-
palatal suture and craniofacial architecture (higher corporate some changes that increase efficiency and
resistance) are contributing factors.25,38 treatment predictability. “MSE new design” uses
As mechanical forces are distributed into the pal- 1.8 mm diameter MI’s and has a robust wrench-type
ate by the MI’s, the stress on teeth and supporting activation key. These changes added greater resis-
structures is understated, which might reduce side tance to both the MI’s and jackscrew. It should be
effects such as gingival recession and buccal bone de- indicated in patients that higher resistance of the cir-
hiscence.20,27,30 A clinical study that followed up 69 cummaxillary sutures is expected.
young adults that underwent MARPE did not find Several MARPE techniques, using various de-
any clinically significant side effects.25 Other stud- signs, are available. Some expanders are supported

© 2017 Dental Press Journal of Orthodontics 122 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
Brunetto DP, Sant’Anna EF, Machado AW, Moon W special article

only by MI (palatal distractors), but most have a hy- Sufficient evidence has been already gathered to
brid design and are supported by both MI and teeth. suggest that all orthodontic patients, adult or pedi-
A technique developed at Yonsei University uses four atric, should undergo an evaluation of the risk of
MI, two of which in the anterior palate, measuring OSAS using validated questionnaires, as a form of
1.8 mm in diameter, and four teeth for anchorage.25 screening.52 Studies in sleep medicine have increas-
It  must be kept in mind that different techniques, ingly highlighted the importance of the orthodontist
with differences particularly in MI and expander po- in the early diagnosis of this syndrome, because the
sitioning, have different outcomes. oral cavity has several signs that potentially indicate
It has been demonstrated that the dimensions of an increased risk of this syndrome, such as the Mal-
the nasal cavity increase in growing patients as a re- lampati classification. This positioning is even more
sult of RPE, and that upper airway resistance may be important in pediatric populations, because the or-
reduced in the short and long terms. 42,43 Other stud- thodontist is one of the first professionals to carefully
ies within several medical specialties have gone fur- assess facial growth and the oral cavity, usually at the
ther and demonstrated that RPE is efficient to treat age of 6 or 7 years old.53 If diagnosed and approached
pediatric patients with OSAS. Orthodontists should correctly at this early age by a multidisciplinary team,
be thoroughly familiar with these longitudinal stud- serious problems such as cardiologic and metabolic
ies, so that they can give up-to-date information to sequelae could be avoided, which OSAS would prob-
their patients, as well as to their colleagues in the ably lead to if undiagnosed.54
multidisciplinary team required for the treatment of No severe complications of MARPE have been
this syndrome.44-47 reported in the literature. The most frequent com-
A recent study found a significant reduction of plication is the inflammation and hyperplasia of
56.2% of the AHI of adult patients that underwent the mucosa around the MI, usually associated with
SARPE, as well as significant improvements of OSAS inadequate local hygiene. A significant amount of
clinical symptoms.48 In the same line of thought about time should be spent to orientate the patient about
MARPE, we may be looking at an interesting treat- hygiene importance, using all the tools to optimize
ment option for patients with OSAS, which, how- it (dental brush and water jet). In cases where me-
ever, precludes the use of invasive osteotomies. Al- chanical control is not sufficient, a chemical method
though the patient reported here had mild apnea, we can be temporarily employed (usually chlorhexidine
currently know that OSAS is progressive, particularly rinse or gel). If inflammation affects only one MI, it
because of the loss of muscle tone and the accumula- should be removed, and the treatment may progress
tion of fat in the cervical region as individuals grow normally. Hyperplasia may also occur when there
older.49 Our patient is still very young, but, at a more is not enough distance from the expander and/or its
advanced age, the condition might deteriorate. In her wires to the mucosa, usually associated with local
current condition, as a result of treatment, we might pain.25 In patients with slow bone remodeling, such
expect her to be able to control OSAS in the future as those with type II diabetes, additional care should
with the help of myofunctional therapy to strengthen be taken to avoid buccosinusal communication af-
the oropharyngeal muscles.50 MARPE efficacy for ter MI removal, as bone neoformation takes longer.
this purpose remains to be proven, and it should be Other systemic conditions should be carefully as-
determined to which groups of patients, with dif- sessed and might contra-indicate the therapy. One
ferent OSAS etiologies, this therapy would be most of the limitations of this technique is associated with
beneficial. However, this treatment may have a high very narrow and high-arched palates, which hinders
impact on individual quality of life and public health, MSE vertical positioning and reduces the success
because moderate/severe OSAS has an estimated rate of the treatment.
prevalence of 23.4% (95% CI, 20.9-26.0) among To our knowledge, this is the first case report to
women and 49.7% (95% CI, 46.6-52.8) among men demonstrate non-surgical resolution of maxillary
(mean age 57 years), which results in substantial costs transverse deficiency associated with OSAS in an
for the public and private health care systems.51 adult patient, evaluated in the short term.

© 2017 Dental Press Journal of Orthodontics 123 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25
special article Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE)

CONCLUSION Microimplant-assisted RPE in adults, in addition

Recent evidence suggests that non-surgical pala- to an efficient solution for maxillary transverse defi-
tal expansion, assisted by microimplants, is achiev- ciency in a substantial number of patients, seems to
able and predictable in young adults. No concrete have an important impact on the reduction of up-
evidence has shown that the palatal suture is com- per airway resistance. The robust skeletal anchor-
pletely fused at the end of facial growth, which age provided by the palatal expander offers novel
makes this treatment theoretically applicable at any mechanical possibilities for the treatment of a wide
age and phase of life. range of malocclusions.

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© 2017 Dental Press Journal of Orthodontics 125 Dental Press J Orthod. 2017 Jan-Feb;22(1):110-25