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Original Article

Korean J Orthod 2022; 52(3): 182-200

Published online May 25, 2022 https://doi.org/10.4041/kjod21.256

Copyright © The Korean Association of Orthodontists.

Effectiveness of miniscrew assisted rapid palatal expansion using cone beam computed tomography: A systematic review and meta-analysis

Patchaya Siddhisaributra , Kornkanok Khlongwanitchakula, Niwat Anuwongnukroha, Somchai Manopatanakulb, Nita Viwattanatipaa

aDepartment of Orthodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
bDepartment of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand

Correspondence to:Nita Viwattanatipa.
Associate Professor, Department of Orthodontics, Faculty of Dentistry, Mahidol University, 6 Yothi Rd. Phaya thai district, Bangkok 10400, Thailand.
Tel +66-86-4008716 e-mail Nitaviw@hotmail.com

How to cite this article: Siddhisaributr P, Khlongwanitchakul K, Anuwongnukroh N, Manopatanakul S, Viwattanatipa N. Effectiveness of miniscrew assisted rapid palatal expansion using cone beam computed tomography: A systematic review and metaanalysis. Korean J Orthod. https://doi.org/10.4041/kjod21.256

Received: October 19, 2021; Accepted: December 18, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective: This study aims to examine the effectiveness of miniscrew assisted rapid palatal expansion (MARPE) treatment in late adolescents and adult patients using cone-beam computed tomography (CBCT). Methods: Literature search was conducted in five electronic databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) based on the PICOS keyword design focusing on MARPE. Out of the 18 CBCT screened outcomes, only nine parameters were sufficient for the quantitative meta-analysis. The parameters were classified into three main groups: 1) skeletal changes, 2) alveolar change, and 3) dental changes. Heterogeneity test, estimation of pooled means, publication bias, sensitivity analysis and risk of bias assessment were also performed. Results: Upon database searching, only 14 full-text articles were qualified from the 364 obtained results. Heterogeneity test indicated the use of the random-effects model. The pooled mean estimate were as follows: 1) Skeletal expansion: zygomatic width, 2.39 mm; nasal width, 2.68 mm; jugular width, 3.12 mm; and midpalatal suture at the posterior nasal spine and anterior nasal spine, 3.34 mm and 4.56 mm, respectively; 2) Alveolar molar width expansion, 4.80 mm; and 3) Dental expansion: inter-canine width, 3.96 mm; inter-premolar width, 4.99 mm and inter-molar width, 5.99 mm. The percentage of expansion demonstrated a skeletal expansion (PNS) of 55.76%, alveolar molar width expansion of 24.37% and dental expansion of 19.87%. Conclusions: In the coronal view, the skeletal and dental expansion created by MARPE was of the pyramidal pattern. MARPE could successfully expand the constricted maxilla in late adolescents and adult patients.

Keywords: Evidence-based orthodontics, Microimplant assisted rapid maxillary expansion, Miniscrew assisted rapid palatal expansion, Maxillary skeletal expansion

Article

Original Article

Korean J Orthod 2022; 52(3): 182-200

Published online May 25, 2022 https://doi.org/10.4041/kjod21.256

Copyright © The Korean Association of Orthodontists.

Effectiveness of miniscrew assisted rapid palatal expansion using cone beam computed tomography: A systematic review and meta-analysis

Patchaya Siddhisaributra , Kornkanok Khlongwanitchakula, Niwat Anuwongnukroha, Somchai Manopatanakulb, Nita Viwattanatipaa

aDepartment of Orthodontics, Faculty of Dentistry, Mahidol University, Bangkok, Thailand
bDepartment of Advanced General Dentistry, Faculty of Dentistry, Mahidol University, Bangkok, Thailand

Correspondence to:Nita Viwattanatipa.
Associate Professor, Department of Orthodontics, Faculty of Dentistry, Mahidol University, 6 Yothi Rd. Phaya thai district, Bangkok 10400, Thailand.
Tel +66-86-4008716 e-mail Nitaviw@hotmail.com

How to cite this article: Siddhisaributr P, Khlongwanitchakul K, Anuwongnukroh N, Manopatanakul S, Viwattanatipa N. Effectiveness of miniscrew assisted rapid palatal expansion using cone beam computed tomography: A systematic review and metaanalysis. Korean J Orthod. https://doi.org/10.4041/kjod21.256

Received: October 19, 2021; Accepted: December 18, 2021

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective: This study aims to examine the effectiveness of miniscrew assisted rapid palatal expansion (MARPE) treatment in late adolescents and adult patients using cone-beam computed tomography (CBCT). Methods: Literature search was conducted in five electronic databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) based on the PICOS keyword design focusing on MARPE. Out of the 18 CBCT screened outcomes, only nine parameters were sufficient for the quantitative meta-analysis. The parameters were classified into three main groups: 1) skeletal changes, 2) alveolar change, and 3) dental changes. Heterogeneity test, estimation of pooled means, publication bias, sensitivity analysis and risk of bias assessment were also performed. Results: Upon database searching, only 14 full-text articles were qualified from the 364 obtained results. Heterogeneity test indicated the use of the random-effects model. The pooled mean estimate were as follows: 1) Skeletal expansion: zygomatic width, 2.39 mm; nasal width, 2.68 mm; jugular width, 3.12 mm; and midpalatal suture at the posterior nasal spine and anterior nasal spine, 3.34 mm and 4.56 mm, respectively; 2) Alveolar molar width expansion, 4.80 mm; and 3) Dental expansion: inter-canine width, 3.96 mm; inter-premolar width, 4.99 mm and inter-molar width, 5.99 mm. The percentage of expansion demonstrated a skeletal expansion (PNS) of 55.76%, alveolar molar width expansion of 24.37% and dental expansion of 19.87%. Conclusions: In the coronal view, the skeletal and dental expansion created by MARPE was of the pyramidal pattern. MARPE could successfully expand the constricted maxilla in late adolescents and adult patients.

Keywords: Evidence-based orthodontics, Microimplant assisted rapid maxillary expansion, Miniscrew assisted rapid palatal expansion, Maxillary skeletal expansion

Fig 1.

Figure 1.PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 2.

Figure 2.Forest plots of skeletal expansion.
PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine; CI, confidence interval.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 3.

Figure 3.Forest plots of alveolar molar width (AMW) expansion.
CI, confidence interval.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 4.

Figure 4.Forest plots of dental expansion.
ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width; CI, confidence interval.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 5.

Figure 5.Funnel plots of skeletal, alveolar molar width, and dental expansion from meta-analysis.
PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 6.

Figure 6.Trim and fill funnel plots of the skeletal, alveolar molar width, and dental expansion from the meta-analysis.
Blue diamonds, mean effect size before trim and fill method; Red diamonds, mean effect size after trim and fill method; PNS, posterior nasal spine; ANS, anterior nasal spine; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Fig 7.

Figure 7.Summary of the adjusted pooled mean estimate of the skeletal, alveolar molar width and dental expansion, unit is millimeters (mm).
ZMW, zygomatic width; NW, nasal width; J-J, jugular width; PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine; AMW, alveolar molar width; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width.
Korean Journal of Orthodontics 2022; 52: 182-200https://doi.org/10.4041/kjod21.256

Table 1 . Inclusion and exclusion criteria: PICOS framework.

Inclusion criteriaExclusion criteria
Participants (P)

- Adult.

- Maxillary transverse deficiency.

- Children, Growing.

- Systemic disease/craniofacial anomalies/syndrome.

Intervention (I)

- Non orthognatic surgery.

- 4 microimplant assisted rapid maxillary expansion.

- MARPE, MSE, MARME.

- In-vitro/Laboratory/Molecular/Cellular/Animal ? Surgery.

- Finite element study.

- RME, RPE, SARPE, SARME.

- Bone distraction.

- Tooth borne RME.

- 2 microimplant assisted rapid maxillary expansion.

Comparison (C): compared vs. post treatment or MARPE vs. SARPE
Outcome measures (O)

- Cone-beam computed tomography (CBCT).

- Skeletal and dental changes.

- Non- CBCT.

Study design (S)

- Randomized controlled trial (RCT).

- Cohort study.

- Case-control study.

- One-group pretest-posttest design.

- Case report/Case series/Opinions/Letter to editor.

- Narrative review/Summary.

- Systematic review/Meta-analysis.

- Non-English.

RME, rapid maxillary expansion; RPE, rapid palatal expansion; MARME, microimplant assisted rapid maxillary expansion; MARPE, miniscrew assisted rapid palatal expansion; MSE, maxillary skeletal expansion; SARME, surgically-assisted RME; SARPE, surgically-assisted RPE..


Table 2 . Study characteristics.

AuthorNStudy designSettingRaceCompareApplianceAppliance designDiameter
length
Mean age (SD)ActivationActivation
period
Success rate
Calil et al.13
(2021)
16Retrospective cohortUniversity Dentistry
Institute
BrazilSelf ligate vs. MARPEPecLab appliance (Belo Horizonte, Brazil)Molar without extension4 titanium mini-implants of 1.8 mm diameter and 8 mm length24.92
(7.6)
2/4-turn a dayUntil the palatal cusps of maxillary first molars touch the buccal cusps of the mandibular first molarsND
Cantarella
et al.16
(2017)
15RetrospectiveUniversityUSANoBioMaterials Korea (Hanam, Korea)Molar without extensionND17.2
(4.2)
2 turns per day, then 1 activation per dayUntil interincisal diastema appear, then complete when maxillary width was equal to mandibular width100%*
Clement
et al.20
(2017)
10ProspectiveUniversityIndiaNoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.8 mm diameter and 11 mm length21.5
(ND)
2 turns per dayUntil the required expansion was achieved100%*
Elkenawy
et al.25
(2020)
31RetrospectiveUniversityUSANoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.5 mm diameter and 11 mm length20.4
(3.2)
2 turns per day, then 1 activation per dayUntil interincisal diastema appear, then complete when maxillary width was equal to mandibular widthND
Jesus
et al.22
(2021)
12Retrospective cohortNDBrazilSARPE with/without cinchPecLab applianceMolar without extension4 titanium mini-implants, NDRange
15?39
2 turns a dayFor 14 to 18 days, until full correctionND
Li et al.26
(2020)
22RetrospectiveUniversityChinaNoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.5 mm diameter and 11 mm length22.6
(4.5)
2 turns every other dayMaxillary skeletal width was no longer less than mandible (mean 38 days)100%*
Li et al.11
(2020)
48RetrospectiveUniversityChinaNoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.5 mm diameter and 11 mm length19.4
(3.3)
One-sixth of turn (0.13 mm) each dayMaxillary skeletal width was no longer less than mandibleND
Lim et al.15
(2017)
24RetrospectiveHospitalKoreaNoHyrax II (Dentaurum, Ispringen, Germany)Molar with anterior arm extension4 titanium mini-implants diameter, 1.8 mm; length, 7 mm; Orlus21.6
(3.1)
Once a day (0.2 mm)Until the required expansion was achieved (5 week)86.84%
Moon
et al.27
(2020)
24RetrospectiveUniversityKoreaC-expanderBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.5 mm diameter and 11 mm length19.2
(5.9)
Once a day (0.2 mm)Until the required expansion was achieved (5 week)ND
Ngan
et al.18
(2018)
8RetrospectiveUniversityUSANoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.8 mm diameterand 11 mm length21.9
(1.5)
Varied with the severity of transverse discrepancyUntil the occlusal aspect of lingual cusp of the maxillary first molars contacted occlusal aspect of the buccal cusp of the mandibular first molars. The 2?3 mm of overexpansion100%*
Nguyen
et al.28
(2021)
20RetrospectiveUniversityKoreaNoBioMaterials KoreaMSE type IIMolar without extension4 titanium mini-implants of 1.8 mm diameterand 11 mm length22.4
(17.6?27.1)
2 turns per day (0.13 mm/turn)Until diastema appeared, after which the rate was reduced to one turn per day, stop when required amount was achieved 20% overexpansion100%*
de
Oliveira
et al.24
(2021)
17/15RetrospectivecohortUniversityBrazilMARPE vs. SARPEPecLab appliance9 mm expanderMolar without extension4 miniscrew unknown diameter and lengthMARPE 26 (11)
SARPE 28.5
(10.5)
2/4 immediately after mini implant placement and 2/4 turns daily (14?18 days)Until full correction86.96%
Park
et al.29
(2017)
14RetrospectiveUniversityKoreaNoHyrax II(Dentaurum, Ispringen, Germany)Molar with anterior arm extensionDiameter, 1.8 mm; length, 7 mm; Orlus20.1
(2.4)
Once a day (0.2 mm)Until the required expansion was achieved84.21%
Tang
et al.7
(2021)
31RetrospectiveUniversityChinaNoBioMaterials KoreaMolar without extension4 titanium mini-implants of 1.5 mm diameterand 11 mm length22.14
(4.76)
Once a day (0.13 mm)Ranging from 40 to 60 turns92%

Table 3 . Outcomes classified by skeletal, alveolar molar width, and dental expansion.

VariableAuthorNMeanSDCombined measurements
ZMWElkenawy et al.25 (2020)313.991.60
Li et al.26 (2020)220.501.00
Li et al.11 (2020)481.770.903 groups*
Tang et al.7 (2021)311.451.04
NWCalil et al.13 (2021)162.821.54
Jesus et al.22 (2021)123.461.95ant./post.*
Li et al.26 (2020)222.301.20
Li et al.11 (2020)483.581.393 groups*
Lim et al.15 (2017)242.201.01
Moon et al.27 (2020)242.451.37
Ngan et al.18 (2018)82.530.53
de Oliveira et al.24 (2021)172.911.62ant./post.*
Tang et al.7 (2021)312.331.22
J-JCalil et al.13 (2021)163.061.81
Jesus et al.22 (2021)123.201.92
Li et al.26 (2020)222.001.00
Li et al.11 (2020)484.691.313 groups*
Tang et al.7 (2021)312.650.98
PNSCantarella et al.16 (2017)154.331.74
Elkenawy et al.25 (2020)314.772.65
Ngan et al.18 (2018)83.270.46
Nguyen et al.28 (2021)203.950.50
de Oliveira et al.24 (2021)172.750.85
ANSCantarella et al.16 (2017)154.752.59
Elkenawy et al.25 (2020)314.981.94
Ngan et al.18 (2018)83.530.80
Nguyen et al.28 (2021)204.830.53
de Oliveira et al.24 (2021)173.691.42

N, sample size; SD, standard deviation; ZMW, zygomatic width; NW, nasal width; J-J, jugular width; PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine..

*Combined mean and SD from multiple groups using an online calculator https://www.statstodo.com/CombineMeansSDs.php.


Table 4 . Outcomes of the AMW and dental expansion.

VariableAuthorNMeanSDCombined
measurements
AMWClement et al.20 (2017)106.501.51
Lim et al.15 (2017)242.600.85
Nguyen et al.28 (2021)204.190.67
de Oliveira et al.24 (2021)173.861.20
ICWCalil et al.13 (2021)163.042.03
Clement et al.20 (2017)105.831.32
Lim et al.15 (2017)243.021.25
IPMWCalil et al.13 (2021)323.632.141st/2nd PM*
Clement et al.20 (2017)205.501.521st/2nd PM*
Lim et al.15 (2017)485.871.261st/2nd PM*
de Oliveira et al.29 (2021)175.212.25
Park et al.29 (2017)145.501.40
IMWCalil et al.13 (2021)166.371.72
Clement et al.20 (2017)107.331.96
Jesus et al.22 (2021)125.822.03
Li et al.11 (2020)486.951.253 groups*
Lim et al.15 (2017)245.631.90
Moon et al.27 (2020)244.911.50
Ngan et al.18 (2018)86.261.31
de Oliveira et al.24 (2021)175.252.34
Park et al.29 (2017)145.401.70

N, sample size; SD, standard deviation; AMW, alveolar molar width; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width; PM, premolar..

*Combined mean and SD from multiple groups using an online calculator https://www.statstodo.com/CombineMeansSDs.php.


Table 5 . Assessment of the heterogeneity and publication bias (Egger’s test) for skeletal, alveolar molar width (AMW), and dental expansion.

GroupParametern/NHeterogeneity testEgger’s regression intercept
Q-valuep-valueI2InterceptSEp-value(2-tailed)
Skeletal expansionZMW4/13297.2410.00096.9155.92911.8150.666
NW9/20233.3820.00076.0350.8722.5690.744
J-J5/129103.5260.00096.136?0.6896.9240.927
PNS5/9139.4770.00089.8680.3373.4670.929
ANS5/9126.2850.00084.782?2.1162.1920.406
Alveolar expansionAMW4/7185.5750.00096.4946.1147.5620.504
Dental expansionICW3/5034.8070.00094.2545.53910.3610.344
IPMW5/13114.4600.00072.337?4.2362.2070.151
IMW9/17346.9700.00082.968?2.5261.8800.221

SE, standard error; ZMW, zygomatic width; NW, nasal width; J-J, jugular width; PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width..


Table 6 . The results of the pooled mean estimate for skeletal, alveolar molar width (AMW), and dental expansion from the meta-analysis including the adjusted values after the method of trim and fill.

GroupParameternNMeanSE95% CI
Skeletal expansionZMW41321.910 (2.385)**0.5480.835, 2.985 (1.120, 3.649)**
NW92022.6750.1792.325, 3.026
J-J51293.1200.5761.990, 4.250
PNS5913.715 (3.337)**0.3033.121, 4.310 (2.754, 3.919)**
ANS5914.335 (4.562)**0.3383.674, 4.997 (3.938, 5.187)**
Alveolar expansionAMW4714.221 (4.799)**0.6083.030, 5.412 (3.112, 6.486)**
Dental expansionICW3503.9590.9262.144, 5.774
IPMW51315.218 (4.992)**0.3554.522, 5.914 (4.229, 5.755)**
IMW91735.9850.3185.361, 6.609

n, number of articles; N, number of subjects; SE, standard error; CI, confidence interval; ZMW, zygomatic width; NW, nasal width; J-J, jugular width; PNS, midpalatal suture at the posterior nasal spine; ANS, midpalatal suture at the anterior nasal spine; ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width..

Values in parenthesis ** = adjusted values after the method of trim and fill..


Table 7 . Assessment of the risk of bias within studies.

StudyStudy designSample sizeSelection descriptionValid measurement methodMethod error analysisBlindingStatisticsConfounding factorsTotal scoreJudged quality standard
Calil et al.13 (2021)011110105Low
Cantarella et al.16 (2017)011110105Low
Clement et al.20 (2017)101100104Low
Elkenawy et al.25 (2020)011110105Low
Jesus et al.22 (2021)001110115Low
Li et al.26 (2020)011110105Low
Li et al.11 (2020)011110105Low
Lim et al.15 (2017)001110104Low
Moon et al.27 (2020)001110104Low
Ngan et al.18 (2018)001110104Low
Nguyen et al.28 (2021)001110104Low
de Oliveira et al.24 (2021)001110115Low
Park et al.29 (2017)001110104Low
Tang et al.7 (2021)001110104Low
Overall estimate4.5Low

Study design: Randomized controlled trial = 3, Prospective = 1, Retrospective = 0, Case series/Case report = 0; Sample size: Adequate (number of samples at least 25 patients) = 1, Inadequate = 0; Selection description: Adequate = 1, Need recalculation = 0; Measurement method: Valid = 1, Invalid = 0; Method error analysis: Yes = 1, No = 0; Blinding in measurement: Yes = 1, No = 0; Statistics: Adequate = 1, Inadequate = 0; Confounding factor stated: Yes = 1, No = 0..

Criteria was modified from the method by Bondemark and Feldmann (Angle Orthod 2006;76:493-501).23.