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Original Article

Korean J Orthod 2022; 52(3): 182-200   https://doi.org/10.4041/kjod21.256

First Published Date April 14, 2022, Publication Date May 25, 2022

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

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

INTRODUCTION

A unilateral or bilateral posterior crossbite, or maxillary transverse deficiency (MTD), are frequently found malocclusions in orthodontic treatment. Other discrepancies associated with MTD may involve the skeletal, dento-alveolar, or soft tissue structure and function, such as, Class II or Class III skeletal malocclusion, excessive vertical alveolar height, functional shift of the mandible, crowding, bucco-lingual tipping of the posterior teeth, etc.1

MTD does not show spontaneous correction and should be treated with maxillary expansion as early as possible.2 Generally, the optimal timing for MTD correction using a conventional rapid palatal expansion (RPE) is preferably below the age of 15.3 Unfortunately, in late adolescents and adults, the midpalatal suture and surrounding maxillary sutures start to fuse and become more rigid resulting in a higher resistance to expansion force.4 Thus, the nonsurgical conventional RPE would be less successful in adult patients and may lead to undesired complications, such as buccal crown tipping of the posterior teeth, pain, tissue swelling, root resorption, marginal bone loss, gingival recession, limited skeletal expansion, failure, and post-expansion relapse.5

Therefore, in adults or from the age of 16 onwards, surgically-assisted RPE (SARPE), is commonly recommended. However, the invasiveness of this surgical procedure, the inherent risks of surgical operation, expensive cost, hospitalization, etc. may pose certain limitations for patients undergoing this procedure.1,6

A non-surgical treatment of MTD in adults, using miniscrew assisted rapid palatal expansion (MARPE), was introduced as a possible alternative for SARPE. It is also known as microimplant assisted rapid maxillary expansion (MARME) or maxillary skeletal expansion (MSE).7 The device is classified mainly as: 1) bone-anchored maxillary expansion (BAME), which is a bone-borne type having no tooth attachment and 2) hybrid design or tooth-bone-anchored maxillary expansion, which combines both bone and tooth support.8,9 MARPE may consist of two to four miniscrews, and may also be mono-cortical or bi-cortical miniscrew anchorage.10,11 Among the appliances used for MARPE, MSE is the type that promotes the bi-cortical engagement of the four miniscrews into the cortical bone of the palate and nasal floor.12

Recent clinical studies using MARPE demonstrated a high success rate of the midpalatal suture separation in young adults, which ranged from 71–92%.1,7,8,13,14 However, failure of the midpalatal suture separation and incidents of asymmetric expansion were reported in some cases.8

In adults, several research papers demonstrated that the transverse expansion of the midpalatal suture, zygomatic bone, temporal bone, lateral pterygoid plate, and nasal cavity occurred to a varied extent using MARPE.7,15 The expansion of the maxilla followed a pyramidal pattern. The least expansion was found at the level of the zygoma, which progressively increased across the palate and the greatest expansion was at dentoalveolar level.8

The pattern of the midpalatal suture separation by MARPE was different from that of conventional RPE. While RPE resulted in a greater degree of opening in the anterior than the posterior palate, majority of the MARPE studies reported the creation of the parallel split pattern of the midpalatal suture.8,12,13,16,17 Moreover, MARPE could create openings between the medial and lateral pterygoid plates without any surgery. The pterygopalatine suture splitting or the pterygomaxillary dysjunction was detectable in 53–84% of the sutures.16,17

Although there were several studies evaluating the skeletal and dental responses of MARPE in adults, its treatment effects still remain controversial. Most of these publications were retrospective with a limited sample size.1,8,14,15,18,19

Only two studies followed a prospective study design.20,21 Recently, Jesus et al.22 compared the effectiveness between MARPE and SARPE in late adolescents and adults, which reported similar effectiveness but less complications with MARPE. To the best of our knowledge, no randomized controlled trial (RCT) publication has been conducted on this issue and, both orthodontists and oral-maxillofacial surgeons may be seeking for more concrete evidence of the effectiveness of MARPE.

Thus, our systematic review and meta-analysis study aimed to evaluate the treatment effect of MARPE, with a specific purpose to summarize the treatment outcomes of MARPE in adult patients in the context of skeletal, alveolar, and dental changes using cone-beam computed tomography (CBCT) evaluation.

MATERIALS AND METHODS

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The Prospero registration number for the study protocol is CRD42021255630.

Eligibility criteria

The PICOS framework was used to construct the inclusion criteria as shown in Table 1.

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.



Search strategy

Five electronic databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were systematically searched up to June 2021. No limits were applied for the language or publication date. Dissertations and conference proceedings retrieved from the electronic database were also included. In addition, secondary search from reference lists of systematic review and meta-analyses articles were manually examined and any papers of interest by title or authors were retrieved for possible inclusion. Details of the advanced search keywords have been provided in Appendix.

Duplicated records were deleted using EndNote® 9 (Clarivate Analytics, Philadelphia, PA, USA). Title and abstract of all the identified articles were independently reviewed by two reviewers (P.S. and K.K.) according to the inclusion/exclusion criteria, in a blinded standardized manner. Disagreements between the reviewers were resolved upon discussion with a third researcher (N.V.).

Data collection

Full text papers were retrieved after title and abstract screening. Two reviewers independently extracted the data from relevant studies according to the full text eligibility criteria, and then recorded the data into a data extraction spreadsheet. The extracted data characteristics included the author, year of publication, sample size, study design, setting, race, comparison groups, appliance, diameter and length of the miniscrew, mean age in years, activation protocol and success rate.

Since the CBCT outcomes reported in literature varied greatly among studies, preliminary screening was necessary to check the adequacy of the number of papers for each value. Overall, 18 skeletal, alveolar, and dental parameters were screened; however, only nine parameters were considered appropriate for the subsequent quantitative analysis. The eligible outcomes were as follows.

  • - Skeletal expansion: zygomatic width (ZMW), nasal width (NW), jugular width (J-J), and the midpalatal suture at the posterior nasal spine (PNS) and the anterior nasal spine (ANS)

  • - Alveolar expansion: alveolar molar width (AMW)

  • - Dental expansion: inter-canine width (ICW), inter-premolar width (IPMW), and inter-molar width (IMW).

Calculation of any raw data that warranted the combined means was carried out with the online application using the sample size, means, and standard deviations in order to obtain the new values.

Meta-analysis

Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)

Forest plots were shown as visual assessment of the heterogeneity across the studies. Statistical heterogeneity was assessed using Cochrane Q-test at 95% confidence interval (CI) (p < 0.05). Moreover, the I2 statistics were used to assess the degree of heterogeneity. The I2 index was defined as low (25%), moderate (50%), or high (75%). If I2 was more than 50%, significant heterogeneity would be considered, and the random effect would be used to estimate the pooled means with 95% CI. Else, the fixed effect model would be used.

Publication bias (Funnel plot and Egger’s test)

In addition, the publication bias was tested using the funnel plot and Egger’s test. If the distribution was equal between each side of the funnel plot, no publication bias was indicated. However, if small studies clustered asymmetrically around the pooled mean estimate line, bias in the study was indicated.

The Egger’s test was used to evaluate the symmetry of the funnel plot. If it was significant (p < 0.05), a publication bias was considered owing to missing studies or heterogeneity.

Sensitivity analysis

The sensitivity test would be performed if any study was considered to be of poor quality or the source of a publication bias. The method trim and fill procedure by Duval and Tweedie was used to correct the publication bias by imputing the hypothesized missing studies for the newly adjusted pooled-mean estimate. In order to err on the safe side, the sensitivity analysis would also be attempted if any case was considered insignificant but with a p-value closed to 0.05.

Subgroup analysis

If the possible causes of the variation of results were detected across studies, a subgroup analysis was performed.

Risk of bias assessment in individual studies

Risk of bias in individual studies was assessed both at the methodology and outcome level by two reviewers (P.S., K.K.). The criteria was modified from the method reported by Feldmann and Bondemark.23 The assessment included study design, sample size, selection description, measurement method, method error analysis, blinding in measurement, statistical method, and confounding factors.

RESULTS

Search strategy

The PRISMA flow diagram demonstrating the search and selection of studies is shown in Figure 1. The initial 364 results from the 5 databases were as follows: PubMed, 84; Embase, 81; Scopus, 97; Web of Science, 83; and Cochrane Library, 19. Through manual searching, 1 article was found from Google Scholar. The remaining 149 articles were screened based on the titles and abstracts. Inter-reviewer agreement on the study eligibility was 96% (6/149). After abstract screening, 29 articles met the inclusion criteria. Thereafter, the full texts were examined. The remaining 15 studies were used in the quantitative analysis. However, since there were two studies by de Oliviera et al.,24 which may have used the same group of subjects, only one study with the most recent information was selected to prevent double-counting of the data. Finally, 14 studies were eligible for the meta-analysis.

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Study characteristics

The characteristics of each study are shown in Table 2. Ten studies were of the retrospective one-group pretest-posttest design.7,11,15,16,18,25-29 Three were retrospective cohort studies,13,22,24 and one was a prospective study.20

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%


The sample size ranged from eight to 48 patients. Considering the appliance design, two studies used modified Hyrax II (Dentaurum, Ispringen, Germany) with extension to the first premolars,15,29 three studies used PecLab appliance (Belo Horizonte, Brazil), and nine studies used BioMaterials Korea (Hanam, Korea). The device of all studies incorporated four titanium miniscrews with diameter of either 1.5 or 1.8 mm. It should be noted that majority of the studies used miniscrews with the length of 11 mm except two studies, which used miniscrews of 7 mm long.15,29 The mean age of most studies was late adolescents to adult patients (> 15 years). The success rate of the midpalatal split ranged from 84% to 100%; however, half of the studies did not report this data.

Meta-analysis

Outcomes of the CBCT measurement from the final recruited papers for skeletal expansion are shown in Table 3. Alveolar molar width and dental expansion are shown in Table 4.

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



Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)

The forest plots of the skeletal, alveolar molar width, and dental expansion are shown in Figure 2, 3, and 4 respectively. The vertical line of the diagram indicates the point estimate of the means and the horizontal line shows the 95% CI.

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.
Figure 3. Forest plots of alveolar molar width (AMW) expansion.
CI, confidence interval.
Figure 4. Forest plots of dental expansion.
ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width; CI, confidence interval.

According to Table 5, the heterogeneity test indicated that the Q-values of all the variables were statistically significant (p < 0.05). Similarly, the I2 index of all the variables were high (> 50%). Therefore, the random effect model was used.

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.



Estimation of the pooled means with 95% CI

The pooled mean estimate with 95% CI of skeletal change is shown in Table 6 and Figure 2. Alveolar change is shown in Table 6 and Figure 3. Dental change is shown in Table 6 and Figure 4.

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.



Publication bias

Visual inspection of the data distribution around funnel plots of all the parameters is shown in Figure 5. Moreover, Egger’s regression (Table 5) was also used to supplement the assessment of the publication bias. The results revealed the non-significant p-value of all the parameters.

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.

Sensitivity analysis

Owing to the small sample size (< 10) and the possible visual detection of the asymmetric distribution in the funnel plots, the possibility of publication bias could not be excluded. The results from the method of trim and fill is shown in Figure 6. The adjusted pooled mean values are shown in Table 6 as the values in parenthesis. The new pooled mean are as follows: ZMW (2.385 mm), PNS (3.337 mm), ANS (4.562 mm), AMW (4.799 mm), and IPMW (4.992 mm).

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.

Finally, subgroup analysis could not be performed since the small sample size of each parameter was less than three in this study.

Risk of bias within studies

The quality assessment of each study is shown in Table 7. All the studies show low level of quality (scores 4–5), mostly due to the study design, which was a retrospective setting. Five studies showed the method of sample size calculation and considered as score 1.11,13,16,25,26 None of the studies showed blinding of the measurement. Only two studies performed the comparison of the confounding factors in the intervention.22,24

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


DISCUSSION

Our systematic review and meta-analysis included data from 14 studies, which assessed the treatment effects of MARPE in late adolescents and adult patients using CBCT evaluation.

In the coronal view, we found the progressive skeletal and dental expansion following a pyramidal pattern (Figure 7). For skeletal change, the greatest expansion was at the ANS (4.56 mm) followed by the PNS (3.34 mm), J-J width (3.12 mm), NW (2.68 mm), and ZMW (2.39 mm). The amount of AMW change was 4.80 mm. Considering the dental change, the greatest expansion was at the IMW (5.99 mm), followed by the IPMW (4.99 mm), and the least expansion was at the ICW (3.96 mm). Overall, the results indicated that MARPE could deliver maxillary expansion in late adolescents and adult patients with differential amount of skeletal expansion, alveolar bone bending, and dental tipping effects.

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.

Skeletal expansion

Our meta-analysis results were generally in agreement with most studies that found the expansion pattern, in coronal perspective, to be largest at the inferior level, which gradually decreased superiorly.7,8,29 The greatest skeletal expansion was at the palate and least expansion at the anatomical structures farther away from the MARPE device. This phenomenon could be explained by the finite element study. It was demonstrated that the stresses distributed from MARPE resulted in tension and compression directed to the palate.30

Midpalatal suture separation

Considering the midpalatal suture separation, majority of the studies reported that MARPE created the parallel split pattern of midpalatal suture.8,12,13,16,17

However, our study showed V-shape expansion pattern with more opening in the anterior (ANS) and less opening in the posterior part (PNS) with a posterior-anterior ratio of 73.25% (adjusted value of PNS 3.34 mm/ANS 4.56 mm). This ratio was less than the value reported by Baik et al.8 who reported a 90% ratio and Cantarella et al.16 who reported an 89.6% ratio (PNS 4.3 mm/ANS 4.8 mm).

Although the skeletal and dental effects of MARPE had been reported by several studies, to our knowledge, only one systematic review paper by Coloccia et al.31 and 1 meta-analysis paper by Kapetanović et al.1 were found. Following the comparative assessment, we found that our study showed superior strength than these two publications, which was attributed to our robust inclusion criteria and homogenous study characteristics.

Comparison of our study with Coloccia et al.31 revealed that only 3 of the recruited papers were the same; however, 11 papers differed from our study. The reason of this dissimilarity was the average age of the several papers in Coloccia et al.’s31 included young children (mean age ranged from 9.3 to 22.6 years). In addition, they also included both bone-borne and hybrid expander supported with either two or four miniscrews, while our study recruited only the hybrid expander with four miniscrews.

In the meta-analysis study by Kapetanović et al.,1 five recruited papers were the same but four papers were different from our study. It should be noted that Kapetanović et al.1 recruited the mixed outcomes measured from CBCT images, two-dimensional radiographs, or dental casts while our study strictly recruited only the CBCT studies. Moreover, the skeletal width increase (2.33 mm) in their study was pooled from various anatomical landmarks, such as the midpalatal suture, jugular, nasal floor, or hard palate while our study separated the levels of these landmarks. Similarly, only one IMW value was reported for dental expansion by Kapetanović et al.1 while our study included the ICW, IPMW, and IMW. Therefore, the validity of the values reported in their study could be questionable. Thus, the pattern of skeletal and dental expansion could be better distinguished in our study.

To our knowledge, only two retrospective cohort studies by Jesus et al.22 and de Oliveira et al.24 compared the effectiveness between MARPE and SARPE in late adolescents and adults. They concluded that MARPE could produce better skeletal changes and parallel palatal expansion with less dentoalveolar changes than SARPE. Our result also demonstrated that MARPE could create skeletal changes with the percentage two times greater than the dental change. However, our V-shape midpalatal suture expansion was not in agreement with the above two papers. Owing to this conflicting point, more cohort or RCT studies are warranted to verify the expansion effect of MARPE in comparison with SARPE.

Dental effect

According to Figure 7 and Table 6, we found that the pattern of dental expansion was dissimilar to the midpalatal suture expansion. The mean dental expansion was greatest at molars, which then reduced progressively towards the canine contradictory to the PNS-ANS expansion pattern. This phenomenon could imply a greater buccally tipping of the maxillary first molar than the premolar and canines, respectively. This buccal tipping of the molar was observed following MARPE, which ranged from 2–8°.15,18,27 Thus, it may be suggested to clinicians that some dental tipping could still occur upon using the MARPE appliance.

Percentage expansion

In our study, the percentage of skeletal expansion (PNS) was 55.76%, AMW expansion was 24.37%, and dental expansion (IMW) was 19.87%. Our results indicated that MARPE promotes twice the amount of skeletal than dental expansion.

Interestingly, the percentage expansion was different among the CBCT studies. Our study and Clement et al.’s20 demonstrated that the percentage of midpalatal suture expansion was above 50%, which was greater than the dental expansion; while the other three CBCT studies showed greater dental expansion than skeletal expansion.15,18,29 These contradictory results could be attributed to the various confounding parameters, such as difference in the anatomical landmarks, appliance design, appliance position, or cortical engagement of miniscrews, etc.

Indirect comparison with SARPE

Most clinicians are interested to know whether MARPE and SARPE with pterygoid dysjunction had comparable effects. Thus far, only one meta-analysis of SARPE was published by Bortolotti et al.32 Indirect comparison with our study demonstrated that the skeletal expansion in SARPE (3.3 mm) accounted for nearly 50% of the total expansion, which was comparable with a MARPE value of 55.76% in our study (3.34 mm at PNS). However, SARPE created greater dental expansion (IMW 7.0 mm) than MARPE (IMW 5.99 mm). The limited evidence at present could imply that MARPE was capable of a more skeletal than dental effect, which could be considered comparable to SARPE.

Limitations

Owing to the fact that the included papers in this study were mostly of retrospective one-group pretest-posttest study design with a small sample size (< 25), it failed to attain high-level quality of evidence, which is a crucial point in evidence-based decision-making.

Residual heterogeneity could also exist in some studies, which could have influenced the results slightly. For example, the mean age of the patients in the studies of Cantarella et al.,16 Li et al.,11 and Moon et al.,27 which was 17.2, 19.4, and 19.2 respectively, may include a few participants who could be around 15 years old. Considering the device design, two studies had the extension arm to the premolars while the rest of studies did not. Also, ICW was included only in three of the studies. In addition, factors which may be associated with MARPE outcomes such as mono- or bi-cortical miniscrew, asymmetric expansion, pterygomaxillary dysjunction could not be evaluated owing to very few studies (less than 3 papers). Thus, these parameters should be included in future studies.

Lastly, clinicians should interpret this conclusion with caution and should consider the potential benefits of the effectiveness of the treatment against its side effects. Besides, further well-designed cohort studies or randomized clinical trials should be conducted in the future to strengthen the conclusion and determine the effectiveness of MARPE.

CONCLUSION

  • In the coronal view, MARPE resulted in skeletal and dental expansion following a pyramidal pattern.

  • The pooled mean effects of skeletal expansion were as follows: ZMW, 2.39 mm; NW, 2.68 mm; J-J, 3.12 mm; PNS, 3.34 mm; and ANS, 4.56 mm.

  • Midpalatal suture split demonstrated a V-shape pattern with greater expansion at the ANS than PNS.

  • Posterior-anterior ratio (PNS/ANS) of midpalatal suture separation was 73.24%.

  • The pooled mean effect of AMW was 4.80 mm.

  • The pooled mean effects of dental expansion were as follows: ICW, 3.96 mm; IPMW, 4.99 mm; and IMW, 5.99 mm.

  • The percentage of effects of the skeletal (PNS), AMW, and dental (IMW) expansion were 55.76%, 19.87%, and 24.37%, respectively.

  • MARPE could expand the constricted maxilla in late adolescents to adult patients.

ACKNOWLEDGEMENTS

The authors would like to acknowledge Faculty of Dentistry, Mahidol University for research funding support.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

References

  1. Kapetanović A, Theodorou CI, Bergé SJ, Schols JGJH, Xi T. Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults: a systematic review and meta-analysis. Eur J Orthod 2021;43:313-23.
    Pubmed KoreaMed CrossRef
  2. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment timing for rapid maxillary expansion. Angle Orthod 2001;71:343-50.
  3. Melsen B, Melsen F. The postnatal development of the palatomaxillary region studied on human autopsy material. Am J Orthod 1982;82:329-42.
    Pubmed CrossRef
  4. Jimenez-Valdivia LM, Malpartida-Carrillo V, Rodríguez-Cárdenas YA, Dias-Da Silveira HL, Arriola-Guillén LE. Midpalatal suture maturation stage assessment in adolescents and young adults using cone-beam computed tomography. Prog Orthod 2019;20:38.
    Pubmed KoreaMed CrossRef
  5. Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical rapid maxillary expansion in adults: report on 47 cases using the Haas expander. Angle Orthod 2000;70:129-44.
    Pubmed CrossRef
  6. Carvalho PHA, Moura LB, Trento GS, Holzinger D, Gabrielli MAC, Gabrielli MFR, et al. Surgically assisted rapid maxillary expansion: a systematic review of complications. Int J Oral Maxillofac Surg 2020;49:325-32.
    Pubmed CrossRef
  7. Tang H, Liu P, Liu X, Hou Y, Chen W, Zhang L, et al. Skeletal width changes after mini-implant-assisted rapid maxillary expansion (MARME) in young adults. Angle Orthod 2021;91:301-6.
    Pubmed KoreaMed CrossRef
  8. Baik HS, Kang YG, Choi YJ. Miniscrew-assisted rapid palatal expansion: a review of recent reports. J World Fed Orthod 2020;9(3S):S54-8.
    Pubmed CrossRef
  9. Sarraj M, Akyalcin S, He H, Xiang J, AlSaty G, Celenk-Koca T, et al. Comparison of skeletal and dentoalveolar changes between pure bone-borne and hybrid tooth-borne and bone-borne maxillary rapid palatal expanders using cone-beam computed tomography. APOS Trends Orthod 2021;11:32-40.
    CrossRef
  10. Lee SY, Choi YJ. Reader's forum: skeletal and dentoalveolar changes after miniscrew-assisted rapid palatal expansion in young adults: a cone-beam computed tomography study. Korean J Orthod 2017;47:213-4.
    Pubmed KoreaMed CrossRef
  11. Li N, Sun W, Li Q, Dong W, Martin D, Guo J. Skeletal effects of monocortical and bicortical mini-implant anchorage on maxillary expansion using cone-beam computed tomography in young adults. Am J Orthod Dentofacial Orthop 2020;157:651-61. Erratum in: Am J Orthod Dentofacial Orthop 2020; 158:318.
    Pubmed CrossRef
  12. Brunetto DP, Sant'Anna EF, Machado AW, Moon W. Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE). Dental Press J Orthod 2017;22:110-25.
    Pubmed KoreaMed CrossRef
  13. Calil RC, Marin Ramirez CM, Otazu A, Torres DM, Gurgel JA, Oliveira RC, et al. Maxillary dental and skeletal effects after treatment with self-ligating appliance and miniscrew-assisted rapid maxillary expansion. Am J Orthod Dentofacial Orthop 2021;159:e93-101.
    Pubmed CrossRef
  14. Choi SH, Shi KK, Cha JY, Park YC, Lee KJ. Nonsurgical miniscrew-assisted rapid maxillary expansion results in acceptable stability in young adults. Angle Orthod 2016;86:713-20.
    Pubmed KoreaMed CrossRef
  15. Lim HM, Park YC, Lee KJ, Kim KH, Choi YJ. Stability of dental, alveolar, and skeletal changes after miniscrew-assisted rapid palatal expansion. Korean J Orthod 2017;47:313-22.
    Pubmed KoreaMed CrossRef
  16. Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34.
    Pubmed KoreaMed CrossRef
  17. Colak O, Paredes NA, Elkenawy I, Torres M, Bui J, Jahangiri S, et al. Tomographic assessment of palatal suture opening pattern and pterygopalatine suture disarticulation in the axial plane after midfacial skeletal expansion. Prog Orthod 2020;21:21.
    Pubmed KoreaMed CrossRef
  18. Ngan P, Nguyen UK, Nguyen T, Tremont T, Martin C. Skeletal, dentoalveolar, and periodontal changes of skeletally matured patients with maxillary deficiency treated with microimplant-assisted rapid palatal expansion appliances: a pilot study. APOS Trends Orthod 2018;8:71-85.
    CrossRef
  19. Shin H, Hwang CJ, Lee KJ, Choi YJ, Han SS, Yu HS. Predictors of midpalatal suture expansion by miniscrew-assisted rapid palatal expansion in young adults: a preliminary study. Korean J Orthod 2019;49:360-71.
    Pubmed KoreaMed CrossRef
  20. Clement EA, Krishnaswamy NR. Skeletal and dentoalveolar changes after skeletal anchorage-assisted rapid palatal expansion in young adults: a cone beam computed tomography study. APOS Trends Orthod 2017;7:113-9.
    CrossRef
  21. Lee SR, Lee JW, Chung DH, Lee SM. Short-term impact of microimplant-assisted rapid palatal expansion on the nasal soft tissues in adults: a three-dimensional stereophotogrammetry study. Korean J Orthod 2020;50:75-85.
    Pubmed KoreaMed CrossRef
  22. Jesus AS, Oliveira CB, Murata WH, Gonçales ES, Pereira-Filho VA, Santos-Pinto A. Nasomaxillary effects of miniscrew-assisted rapid palatal expansion and two surgically assisted rapid palatal expansion approaches. Int J Oral Maxillofac Surg 2021;50:1059-68.
    Pubmed CrossRef
  23. Feldmann I, Bondemark L. Orthodontic anchorage: a systematic review. Angle Orthod 2006;76:493-501.
  24. de Oliveira CB, Ayub P, Ledra IM, Murata WH, Suzuki SS, Ravelli DB, et al. Microimplant assisted rapid palatal expansion vs surgically assisted rapid palatal expansion for maxillary transverse discrepancy treatment. Am J Orthod Dentofacial Orthop 2021;159:733-42.
    Pubmed CrossRef
  25. Elkenawy I, Fijany L, Colak O, Paredes NA, Gargoum A, Abedini S, et al. An assessment of the magnitude, parallelism, and asymmetry of micro-implant-assisted rapid maxillary expansion in non-growing patients. Prog Orthod 2020;21:42.
    Pubmed KoreaMed CrossRef
  26. Li Q, Tang H, Liu X, Luo Q, Jiang Z, Martin D, et al. Comparison of dimensions and volume of upper airway before and after mini-implant assisted rapid maxillary expansion. Angle Orthod 2020;90:432-41.
    Pubmed KoreaMed CrossRef
  27. Moon HW, Kim MJ, Ahn HW, Kim SJ, Kim SH, Chung KR, et al. Molar inclination and surrounding alveolar bone change relative to the design of bone-borne maxillary expanders: a CBCT study. Angle Orthod 2020;90:13-22.
    Pubmed KoreaMed CrossRef
  28. Nguyen H, Shin JW, Giap HV, Kim KB, Chae HS, Kim YH, et al. Midfacial soft tissue changes after maxillary expansion using micro-implant-supported maxillary skeletal expanders in young adults: a retrospective study. Korean J Orthod 2021;51:145-56.
    Pubmed KoreaMed CrossRef
  29. Park JJ, Park YC, Lee KJ, Cha JY, Tahk JH, Choi YJ. Skeletal and dentoalveolar changes after miniscrew-assisted rapid palatal expansion in young adults: a cone-beam computed tomography study. Korean J Orthod 2017;47:77-86.
    Pubmed KoreaMed CrossRef
  30. MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W. The effects of micro-implant assisted rapid palatal expansion (MARPE) on the nasomaxillary complex--a finite element method (FEM) analysis. Prog Orthod 2014;15:52.
    Pubmed KoreaMed CrossRef
  31. Coloccia G, Inchingolo AD, Inchingolo AM, Malcangi G, Montenegro V, Patano A, et al. Effectiveness of dental and maxillary transverse changes in tooth-borne, bone-borne, and hybrid palatal expansion through cone-beam tomography: a systematic review of the literature. Medicina (Kaunas) 2021;57:288.
    Pubmed KoreaMed CrossRef
  32. Bortolotti F, Solidoro L, Bartolucci ML, Incerti Parenti S, Paganelli C, Alessandri-Bonetti G. Skeletal and dental effects of surgically assisted rapid palatal expansion: a systematic review of randomized controlled trials. Eur J Orthod 2020;42:434-40.
    Pubmed CrossRef

Article

Original Article

Korean J Orthod 2022; 52(3): 182-200   https://doi.org/10.4041/kjod21.256

First Published Date April 14, 2022, Publication Date May 25, 2022

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

INTRODUCTION

A unilateral or bilateral posterior crossbite, or maxillary transverse deficiency (MTD), are frequently found malocclusions in orthodontic treatment. Other discrepancies associated with MTD may involve the skeletal, dento-alveolar, or soft tissue structure and function, such as, Class II or Class III skeletal malocclusion, excessive vertical alveolar height, functional shift of the mandible, crowding, bucco-lingual tipping of the posterior teeth, etc.1

MTD does not show spontaneous correction and should be treated with maxillary expansion as early as possible.2 Generally, the optimal timing for MTD correction using a conventional rapid palatal expansion (RPE) is preferably below the age of 15.3 Unfortunately, in late adolescents and adults, the midpalatal suture and surrounding maxillary sutures start to fuse and become more rigid resulting in a higher resistance to expansion force.4 Thus, the nonsurgical conventional RPE would be less successful in adult patients and may lead to undesired complications, such as buccal crown tipping of the posterior teeth, pain, tissue swelling, root resorption, marginal bone loss, gingival recession, limited skeletal expansion, failure, and post-expansion relapse.5

Therefore, in adults or from the age of 16 onwards, surgically-assisted RPE (SARPE), is commonly recommended. However, the invasiveness of this surgical procedure, the inherent risks of surgical operation, expensive cost, hospitalization, etc. may pose certain limitations for patients undergoing this procedure.1,6

A non-surgical treatment of MTD in adults, using miniscrew assisted rapid palatal expansion (MARPE), was introduced as a possible alternative for SARPE. It is also known as microimplant assisted rapid maxillary expansion (MARME) or maxillary skeletal expansion (MSE).7 The device is classified mainly as: 1) bone-anchored maxillary expansion (BAME), which is a bone-borne type having no tooth attachment and 2) hybrid design or tooth-bone-anchored maxillary expansion, which combines both bone and tooth support.8,9 MARPE may consist of two to four miniscrews, and may also be mono-cortical or bi-cortical miniscrew anchorage.10,11 Among the appliances used for MARPE, MSE is the type that promotes the bi-cortical engagement of the four miniscrews into the cortical bone of the palate and nasal floor.12

Recent clinical studies using MARPE demonstrated a high success rate of the midpalatal suture separation in young adults, which ranged from 71–92%.1,7,8,13,14 However, failure of the midpalatal suture separation and incidents of asymmetric expansion were reported in some cases.8

In adults, several research papers demonstrated that the transverse expansion of the midpalatal suture, zygomatic bone, temporal bone, lateral pterygoid plate, and nasal cavity occurred to a varied extent using MARPE.7,15 The expansion of the maxilla followed a pyramidal pattern. The least expansion was found at the level of the zygoma, which progressively increased across the palate and the greatest expansion was at dentoalveolar level.8

The pattern of the midpalatal suture separation by MARPE was different from that of conventional RPE. While RPE resulted in a greater degree of opening in the anterior than the posterior palate, majority of the MARPE studies reported the creation of the parallel split pattern of the midpalatal suture.8,12,13,16,17 Moreover, MARPE could create openings between the medial and lateral pterygoid plates without any surgery. The pterygopalatine suture splitting or the pterygomaxillary dysjunction was detectable in 53–84% of the sutures.16,17

Although there were several studies evaluating the skeletal and dental responses of MARPE in adults, its treatment effects still remain controversial. Most of these publications were retrospective with a limited sample size.1,8,14,15,18,19

Only two studies followed a prospective study design.20,21 Recently, Jesus et al.22 compared the effectiveness between MARPE and SARPE in late adolescents and adults, which reported similar effectiveness but less complications with MARPE. To the best of our knowledge, no randomized controlled trial (RCT) publication has been conducted on this issue and, both orthodontists and oral-maxillofacial surgeons may be seeking for more concrete evidence of the effectiveness of MARPE.

Thus, our systematic review and meta-analysis study aimed to evaluate the treatment effect of MARPE, with a specific purpose to summarize the treatment outcomes of MARPE in adult patients in the context of skeletal, alveolar, and dental changes using cone-beam computed tomography (CBCT) evaluation.

MATERIALS AND METHODS

This meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The Prospero registration number for the study protocol is CRD42021255630.

Eligibility criteria

The PICOS framework was used to construct the inclusion criteria as shown in Table 1.

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..



Search strategy

Five electronic databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) were systematically searched up to June 2021. No limits were applied for the language or publication date. Dissertations and conference proceedings retrieved from the electronic database were also included. In addition, secondary search from reference lists of systematic review and meta-analyses articles were manually examined and any papers of interest by title or authors were retrieved for possible inclusion. Details of the advanced search keywords have been provided in Appendix.

Duplicated records were deleted using EndNote® 9 (Clarivate Analytics, Philadelphia, PA, USA). Title and abstract of all the identified articles were independently reviewed by two reviewers (P.S. and K.K.) according to the inclusion/exclusion criteria, in a blinded standardized manner. Disagreements between the reviewers were resolved upon discussion with a third researcher (N.V.).

Data collection

Full text papers were retrieved after title and abstract screening. Two reviewers independently extracted the data from relevant studies according to the full text eligibility criteria, and then recorded the data into a data extraction spreadsheet. The extracted data characteristics included the author, year of publication, sample size, study design, setting, race, comparison groups, appliance, diameter and length of the miniscrew, mean age in years, activation protocol and success rate.

Since the CBCT outcomes reported in literature varied greatly among studies, preliminary screening was necessary to check the adequacy of the number of papers for each value. Overall, 18 skeletal, alveolar, and dental parameters were screened; however, only nine parameters were considered appropriate for the subsequent quantitative analysis. The eligible outcomes were as follows.

  • - Skeletal expansion: zygomatic width (ZMW), nasal width (NW), jugular width (J-J), and the midpalatal suture at the posterior nasal spine (PNS) and the anterior nasal spine (ANS)

  • - Alveolar expansion: alveolar molar width (AMW)

  • - Dental expansion: inter-canine width (ICW), inter-premolar width (IPMW), and inter-molar width (IMW).

Calculation of any raw data that warranted the combined means was carried out with the online application using the sample size, means, and standard deviations in order to obtain the new values.

Meta-analysis

Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)

Forest plots were shown as visual assessment of the heterogeneity across the studies. Statistical heterogeneity was assessed using Cochrane Q-test at 95% confidence interval (CI) (p < 0.05). Moreover, the I2 statistics were used to assess the degree of heterogeneity. The I2 index was defined as low (25%), moderate (50%), or high (75%). If I2 was more than 50%, significant heterogeneity would be considered, and the random effect would be used to estimate the pooled means with 95% CI. Else, the fixed effect model would be used.

Publication bias (Funnel plot and Egger’s test)

In addition, the publication bias was tested using the funnel plot and Egger’s test. If the distribution was equal between each side of the funnel plot, no publication bias was indicated. However, if small studies clustered asymmetrically around the pooled mean estimate line, bias in the study was indicated.

The Egger’s test was used to evaluate the symmetry of the funnel plot. If it was significant (p < 0.05), a publication bias was considered owing to missing studies or heterogeneity.

Sensitivity analysis

The sensitivity test would be performed if any study was considered to be of poor quality or the source of a publication bias. The method trim and fill procedure by Duval and Tweedie was used to correct the publication bias by imputing the hypothesized missing studies for the newly adjusted pooled-mean estimate. In order to err on the safe side, the sensitivity analysis would also be attempted if any case was considered insignificant but with a p-value closed to 0.05.

Subgroup analysis

If the possible causes of the variation of results were detected across studies, a subgroup analysis was performed.

Risk of bias assessment in individual studies

Risk of bias in individual studies was assessed both at the methodology and outcome level by two reviewers (P.S., K.K.). The criteria was modified from the method reported by Feldmann and Bondemark.23 The assessment included study design, sample size, selection description, measurement method, method error analysis, blinding in measurement, statistical method, and confounding factors.

RESULTS

Search strategy

The PRISMA flow diagram demonstrating the search and selection of studies is shown in Figure 1. The initial 364 results from the 5 databases were as follows: PubMed, 84; Embase, 81; Scopus, 97; Web of Science, 83; and Cochrane Library, 19. Through manual searching, 1 article was found from Google Scholar. The remaining 149 articles were screened based on the titles and abstracts. Inter-reviewer agreement on the study eligibility was 96% (6/149). After abstract screening, 29 articles met the inclusion criteria. Thereafter, the full texts were examined. The remaining 15 studies were used in the quantitative analysis. However, since there were two studies by de Oliviera et al.,24 which may have used the same group of subjects, only one study with the most recent information was selected to prevent double-counting of the data. Finally, 14 studies were eligible for the meta-analysis.

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.

Study characteristics

The characteristics of each study are shown in Table 2. Ten studies were of the retrospective one-group pretest-posttest design.7,11,15,16,18,25-29 Three were retrospective cohort studies,13,22,24 and one was a prospective study.20

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%


The sample size ranged from eight to 48 patients. Considering the appliance design, two studies used modified Hyrax II (Dentaurum, Ispringen, Germany) with extension to the first premolars,15,29 three studies used PecLab appliance (Belo Horizonte, Brazil), and nine studies used BioMaterials Korea (Hanam, Korea). The device of all studies incorporated four titanium miniscrews with diameter of either 1.5 or 1.8 mm. It should be noted that majority of the studies used miniscrews with the length of 11 mm except two studies, which used miniscrews of 7 mm long.15,29 The mean age of most studies was late adolescents to adult patients (> 15 years). The success rate of the midpalatal split ranged from 84% to 100%; however, half of the studies did not report this data.

Meta-analysis

Outcomes of the CBCT measurement from the final recruited papers for skeletal expansion are shown in Table 3. Alveolar molar width and dental expansion are shown in Table 4.

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.



Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)

The forest plots of the skeletal, alveolar molar width, and dental expansion are shown in Figure 2, 3, and 4 respectively. The vertical line of the diagram indicates the point estimate of the means and the horizontal line shows the 95% CI.

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.
Figure 3. Forest plots of alveolar molar width (AMW) expansion.
CI, confidence interval.
Figure 4. Forest plots of dental expansion.
ICW, inter-canine width; IPMW, inter-premolar width; IMW, inter-molar width; CI, confidence interval.

According to Table 5, the heterogeneity test indicated that the Q-values of all the variables were statistically significant (p < 0.05). Similarly, the I2 index of all the variables were high (> 50%). Therefore, the random effect model was used.

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..



Estimation of the pooled means with 95% CI

The pooled mean estimate with 95% CI of skeletal change is shown in Table 6 and Figure 2. Alveolar change is shown in Table 6 and Figure 3. Dental change is shown in Table 6 and Figure 4.

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..



Publication bias

Visual inspection of the data distribution around funnel plots of all the parameters is shown in Figure 5. Moreover, Egger’s regression (Table 5) was also used to supplement the assessment of the publication bias. The results revealed the non-significant p-value of all the parameters.

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.

Sensitivity analysis

Owing to the small sample size (< 10) and the possible visual detection of the asymmetric distribution in the funnel plots, the possibility of publication bias could not be excluded. The results from the method of trim and fill is shown in Figure 6. The adjusted pooled mean values are shown in Table 6 as the values in parenthesis. The new pooled mean are as follows: ZMW (2.385 mm), PNS (3.337 mm), ANS (4.562 mm), AMW (4.799 mm), and IPMW (4.992 mm).

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.

Finally, subgroup analysis could not be performed since the small sample size of each parameter was less than three in this study.

Risk of bias within studies

The quality assessment of each study is shown in Table 7. All the studies show low level of quality (scores 4–5), mostly due to the study design, which was a retrospective setting. Five studies showed the method of sample size calculation and considered as score 1.11,13,16,25,26 None of the studies showed blinding of the measurement. Only two studies performed the comparison of the confounding factors in the intervention.22,24

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.


DISCUSSION

Our systematic review and meta-analysis included data from 14 studies, which assessed the treatment effects of MARPE in late adolescents and adult patients using CBCT evaluation.

In the coronal view, we found the progressive skeletal and dental expansion following a pyramidal pattern (Figure 7). For skeletal change, the greatest expansion was at the ANS (4.56 mm) followed by the PNS (3.34 mm), J-J width (3.12 mm), NW (2.68 mm), and ZMW (2.39 mm). The amount of AMW change was 4.80 mm. Considering the dental change, the greatest expansion was at the IMW (5.99 mm), followed by the IPMW (4.99 mm), and the least expansion was at the ICW (3.96 mm). Overall, the results indicated that MARPE could deliver maxillary expansion in late adolescents and adult patients with differential amount of skeletal expansion, alveolar bone bending, and dental tipping effects.

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.

Skeletal expansion

Our meta-analysis results were generally in agreement with most studies that found the expansion pattern, in coronal perspective, to be largest at the inferior level, which gradually decreased superiorly.7,8,29 The greatest skeletal expansion was at the palate and least expansion at the anatomical structures farther away from the MARPE device. This phenomenon could be explained by the finite element study. It was demonstrated that the stresses distributed from MARPE resulted in tension and compression directed to the palate.30

Midpalatal suture separation

Considering the midpalatal suture separation, majority of the studies reported that MARPE created the parallel split pattern of midpalatal suture.8,12,13,16,17

However, our study showed V-shape expansion pattern with more opening in the anterior (ANS) and less opening in the posterior part (PNS) with a posterior-anterior ratio of 73.25% (adjusted value of PNS 3.34 mm/ANS 4.56 mm). This ratio was less than the value reported by Baik et al.8 who reported a 90% ratio and Cantarella et al.16 who reported an 89.6% ratio (PNS 4.3 mm/ANS 4.8 mm).

Although the skeletal and dental effects of MARPE had been reported by several studies, to our knowledge, only one systematic review paper by Coloccia et al.31 and 1 meta-analysis paper by Kapetanović et al.1 were found. Following the comparative assessment, we found that our study showed superior strength than these two publications, which was attributed to our robust inclusion criteria and homogenous study characteristics.

Comparison of our study with Coloccia et al.31 revealed that only 3 of the recruited papers were the same; however, 11 papers differed from our study. The reason of this dissimilarity was the average age of the several papers in Coloccia et al.’s31 included young children (mean age ranged from 9.3 to 22.6 years). In addition, they also included both bone-borne and hybrid expander supported with either two or four miniscrews, while our study recruited only the hybrid expander with four miniscrews.

In the meta-analysis study by Kapetanović et al.,1 five recruited papers were the same but four papers were different from our study. It should be noted that Kapetanović et al.1 recruited the mixed outcomes measured from CBCT images, two-dimensional radiographs, or dental casts while our study strictly recruited only the CBCT studies. Moreover, the skeletal width increase (2.33 mm) in their study was pooled from various anatomical landmarks, such as the midpalatal suture, jugular, nasal floor, or hard palate while our study separated the levels of these landmarks. Similarly, only one IMW value was reported for dental expansion by Kapetanović et al.1 while our study included the ICW, IPMW, and IMW. Therefore, the validity of the values reported in their study could be questionable. Thus, the pattern of skeletal and dental expansion could be better distinguished in our study.

To our knowledge, only two retrospective cohort studies by Jesus et al.22 and de Oliveira et al.24 compared the effectiveness between MARPE and SARPE in late adolescents and adults. They concluded that MARPE could produce better skeletal changes and parallel palatal expansion with less dentoalveolar changes than SARPE. Our result also demonstrated that MARPE could create skeletal changes with the percentage two times greater than the dental change. However, our V-shape midpalatal suture expansion was not in agreement with the above two papers. Owing to this conflicting point, more cohort or RCT studies are warranted to verify the expansion effect of MARPE in comparison with SARPE.

Dental effect

According to Figure 7 and Table 6, we found that the pattern of dental expansion was dissimilar to the midpalatal suture expansion. The mean dental expansion was greatest at molars, which then reduced progressively towards the canine contradictory to the PNS-ANS expansion pattern. This phenomenon could imply a greater buccally tipping of the maxillary first molar than the premolar and canines, respectively. This buccal tipping of the molar was observed following MARPE, which ranged from 2–8°.15,18,27 Thus, it may be suggested to clinicians that some dental tipping could still occur upon using the MARPE appliance.

Percentage expansion

In our study, the percentage of skeletal expansion (PNS) was 55.76%, AMW expansion was 24.37%, and dental expansion (IMW) was 19.87%. Our results indicated that MARPE promotes twice the amount of skeletal than dental expansion.

Interestingly, the percentage expansion was different among the CBCT studies. Our study and Clement et al.’s20 demonstrated that the percentage of midpalatal suture expansion was above 50%, which was greater than the dental expansion; while the other three CBCT studies showed greater dental expansion than skeletal expansion.15,18,29 These contradictory results could be attributed to the various confounding parameters, such as difference in the anatomical landmarks, appliance design, appliance position, or cortical engagement of miniscrews, etc.

Indirect comparison with SARPE

Most clinicians are interested to know whether MARPE and SARPE with pterygoid dysjunction had comparable effects. Thus far, only one meta-analysis of SARPE was published by Bortolotti et al.32 Indirect comparison with our study demonstrated that the skeletal expansion in SARPE (3.3 mm) accounted for nearly 50% of the total expansion, which was comparable with a MARPE value of 55.76% in our study (3.34 mm at PNS). However, SARPE created greater dental expansion (IMW 7.0 mm) than MARPE (IMW 5.99 mm). The limited evidence at present could imply that MARPE was capable of a more skeletal than dental effect, which could be considered comparable to SARPE.

Limitations

Owing to the fact that the included papers in this study were mostly of retrospective one-group pretest-posttest study design with a small sample size (< 25), it failed to attain high-level quality of evidence, which is a crucial point in evidence-based decision-making.

Residual heterogeneity could also exist in some studies, which could have influenced the results slightly. For example, the mean age of the patients in the studies of Cantarella et al.,16 Li et al.,11 and Moon et al.,27 which was 17.2, 19.4, and 19.2 respectively, may include a few participants who could be around 15 years old. Considering the device design, two studies had the extension arm to the premolars while the rest of studies did not. Also, ICW was included only in three of the studies. In addition, factors which may be associated with MARPE outcomes such as mono- or bi-cortical miniscrew, asymmetric expansion, pterygomaxillary dysjunction could not be evaluated owing to very few studies (less than 3 papers). Thus, these parameters should be included in future studies.

Lastly, clinicians should interpret this conclusion with caution and should consider the potential benefits of the effectiveness of the treatment against its side effects. Besides, further well-designed cohort studies or randomized clinical trials should be conducted in the future to strengthen the conclusion and determine the effectiveness of MARPE.

CONCLUSION

  • In the coronal view, MARPE resulted in skeletal and dental expansion following a pyramidal pattern.

  • The pooled mean effects of skeletal expansion were as follows: ZMW, 2.39 mm; NW, 2.68 mm; J-J, 3.12 mm; PNS, 3.34 mm; and ANS, 4.56 mm.

  • Midpalatal suture split demonstrated a V-shape pattern with greater expansion at the ANS than PNS.

  • Posterior-anterior ratio (PNS/ANS) of midpalatal suture separation was 73.24%.

  • The pooled mean effect of AMW was 4.80 mm.

  • The pooled mean effects of dental expansion were as follows: ICW, 3.96 mm; IPMW, 4.99 mm; and IMW, 5.99 mm.

  • The percentage of effects of the skeletal (PNS), AMW, and dental (IMW) expansion were 55.76%, 19.87%, and 24.37%, respectively.

  • MARPE could expand the constricted maxilla in late adolescents to adult patients.

ACKNOWLEDGEMENTS

The authors would like to acknowledge Faculty of Dentistry, Mahidol University for research funding support.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

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.


References

  1. Kapetanović A, Theodorou CI, Bergé SJ, Schols JGJH, Xi T. Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults: a systematic review and meta-analysis. Eur J Orthod 2021;43:313-23.
    Pubmed KoreaMed CrossRef
  2. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr. Treatment timing for rapid maxillary expansion. Angle Orthod 2001;71:343-50.
  3. Melsen B, Melsen F. The postnatal development of the palatomaxillary region studied on human autopsy material. Am J Orthod 1982;82:329-42.
    Pubmed CrossRef
  4. Jimenez-Valdivia LM, Malpartida-Carrillo V, Rodríguez-Cárdenas YA, Dias-Da Silveira HL, Arriola-Guillén LE. Midpalatal suture maturation stage assessment in adolescents and young adults using cone-beam computed tomography. Prog Orthod 2019;20:38.
    Pubmed KoreaMed CrossRef
  5. Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical rapid maxillary expansion in adults: report on 47 cases using the Haas expander. Angle Orthod 2000;70:129-44.
    Pubmed CrossRef
  6. Carvalho PHA, Moura LB, Trento GS, Holzinger D, Gabrielli MAC, Gabrielli MFR, et al. Surgically assisted rapid maxillary expansion: a systematic review of complications. Int J Oral Maxillofac Surg 2020;49:325-32.
    Pubmed CrossRef
  7. Tang H, Liu P, Liu X, Hou Y, Chen W, Zhang L, et al. Skeletal width changes after mini-implant-assisted rapid maxillary expansion (MARME) in young adults. Angle Orthod 2021;91:301-6.
    Pubmed KoreaMed CrossRef
  8. Baik HS, Kang YG, Choi YJ. Miniscrew-assisted rapid palatal expansion: a review of recent reports. J World Fed Orthod 2020;9(3S):S54-8.
    Pubmed CrossRef
  9. Sarraj M, Akyalcin S, He H, Xiang J, AlSaty G, Celenk-Koca T, et al. Comparison of skeletal and dentoalveolar changes between pure bone-borne and hybrid tooth-borne and bone-borne maxillary rapid palatal expanders using cone-beam computed tomography. APOS Trends Orthod 2021;11:32-40.
    CrossRef
  10. Lee SY, Choi YJ. Reader's forum: skeletal and dentoalveolar changes after miniscrew-assisted rapid palatal expansion in young adults: a cone-beam computed tomography study. Korean J Orthod 2017;47:213-4.
    Pubmed KoreaMed CrossRef
  11. Li N, Sun W, Li Q, Dong W, Martin D, Guo J. Skeletal effects of monocortical and bicortical mini-implant anchorage on maxillary expansion using cone-beam computed tomography in young adults. Am J Orthod Dentofacial Orthop 2020;157:651-61. Erratum in: Am J Orthod Dentofacial Orthop 2020; 158:318.
    Pubmed CrossRef
  12. Brunetto DP, Sant'Anna EF, Machado AW, Moon W. Non-surgical treatment of transverse deficiency in adults using Microimplant-assisted Rapid Palatal Expansion (MARPE). Dental Press J Orthod 2017;22:110-25.
    Pubmed KoreaMed CrossRef
  13. Calil RC, Marin Ramirez CM, Otazu A, Torres DM, Gurgel JA, Oliveira RC, et al. Maxillary dental and skeletal effects after treatment with self-ligating appliance and miniscrew-assisted rapid maxillary expansion. Am J Orthod Dentofacial Orthop 2021;159:e93-101.
    Pubmed CrossRef
  14. Choi SH, Shi KK, Cha JY, Park YC, Lee KJ. Nonsurgical miniscrew-assisted rapid maxillary expansion results in acceptable stability in young adults. Angle Orthod 2016;86:713-20.
    Pubmed KoreaMed CrossRef
  15. Lim HM, Park YC, Lee KJ, Kim KH, Choi YJ. Stability of dental, alveolar, and skeletal changes after miniscrew-assisted rapid palatal expansion. Korean J Orthod 2017;47:313-22.
    Pubmed KoreaMed CrossRef
  16. Cantarella D, Dominguez-Mompell R, Mallya SM, Moschik C, Pan HC, Miller J, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod 2017;18:34.
    Pubmed KoreaMed CrossRef
  17. Colak O, Paredes NA, Elkenawy I, Torres M, Bui J, Jahangiri S, et al. Tomographic assessment of palatal suture opening pattern and pterygopalatine suture disarticulation in the axial plane after midfacial skeletal expansion. Prog Orthod 2020;21:21.
    Pubmed KoreaMed CrossRef
  18. Ngan P, Nguyen UK, Nguyen T, Tremont T, Martin C. Skeletal, dentoalveolar, and periodontal changes of skeletally matured patients with maxillary deficiency treated with microimplant-assisted rapid palatal expansion appliances: a pilot study. APOS Trends Orthod 2018;8:71-85.
    CrossRef
  19. Shin H, Hwang CJ, Lee KJ, Choi YJ, Han SS, Yu HS. Predictors of midpalatal suture expansion by miniscrew-assisted rapid palatal expansion in young adults: a preliminary study. Korean J Orthod 2019;49:360-71.
    Pubmed KoreaMed CrossRef
  20. Clement EA, Krishnaswamy NR. Skeletal and dentoalveolar changes after skeletal anchorage-assisted rapid palatal expansion in young adults: a cone beam computed tomography study. APOS Trends Orthod 2017;7:113-9.
    CrossRef
  21. Lee SR, Lee JW, Chung DH, Lee SM. Short-term impact of microimplant-assisted rapid palatal expansion on the nasal soft tissues in adults: a three-dimensional stereophotogrammetry study. Korean J Orthod 2020;50:75-85.
    Pubmed KoreaMed CrossRef
  22. Jesus AS, Oliveira CB, Murata WH, Gonçales ES, Pereira-Filho VA, Santos-Pinto A. Nasomaxillary effects of miniscrew-assisted rapid palatal expansion and two surgically assisted rapid palatal expansion approaches. Int J Oral Maxillofac Surg 2021;50:1059-68.
    Pubmed CrossRef
  23. Feldmann I, Bondemark L. Orthodontic anchorage: a systematic review. Angle Orthod 2006;76:493-501.
  24. de Oliveira CB, Ayub P, Ledra IM, Murata WH, Suzuki SS, Ravelli DB, et al. Microimplant assisted rapid palatal expansion vs surgically assisted rapid palatal expansion for maxillary transverse discrepancy treatment. Am J Orthod Dentofacial Orthop 2021;159:733-42.
    Pubmed CrossRef
  25. Elkenawy I, Fijany L, Colak O, Paredes NA, Gargoum A, Abedini S, et al. An assessment of the magnitude, parallelism, and asymmetry of micro-implant-assisted rapid maxillary expansion in non-growing patients. Prog Orthod 2020;21:42.
    Pubmed KoreaMed CrossRef
  26. Li Q, Tang H, Liu X, Luo Q, Jiang Z, Martin D, et al. Comparison of dimensions and volume of upper airway before and after mini-implant assisted rapid maxillary expansion. Angle Orthod 2020;90:432-41.
    Pubmed KoreaMed CrossRef
  27. Moon HW, Kim MJ, Ahn HW, Kim SJ, Kim SH, Chung KR, et al. Molar inclination and surrounding alveolar bone change relative to the design of bone-borne maxillary expanders: a CBCT study. Angle Orthod 2020;90:13-22.
    Pubmed KoreaMed CrossRef
  28. Nguyen H, Shin JW, Giap HV, Kim KB, Chae HS, Kim YH, et al. Midfacial soft tissue changes after maxillary expansion using micro-implant-supported maxillary skeletal expanders in young adults: a retrospective study. Korean J Orthod 2021;51:145-56.
    Pubmed KoreaMed CrossRef
  29. Park JJ, Park YC, Lee KJ, Cha JY, Tahk JH, Choi YJ. Skeletal and dentoalveolar changes after miniscrew-assisted rapid palatal expansion in young adults: a cone-beam computed tomography study. Korean J Orthod 2017;47:77-86.
    Pubmed KoreaMed CrossRef
  30. MacGinnis M, Chu H, Youssef G, Wu KW, Machado AW, Moon W. The effects of micro-implant assisted rapid palatal expansion (MARPE) on the nasomaxillary complex--a finite element method (FEM) analysis. Prog Orthod 2014;15:52.
    Pubmed KoreaMed CrossRef
  31. Coloccia G, Inchingolo AD, Inchingolo AM, Malcangi G, Montenegro V, Patano A, et al. Effectiveness of dental and maxillary transverse changes in tooth-borne, bone-borne, and hybrid palatal expansion through cone-beam tomography: a systematic review of the literature. Medicina (Kaunas) 2021;57:288.
    Pubmed KoreaMed CrossRef
  32. Bortolotti F, Solidoro L, Bartolucci ML, Incerti Parenti S, Paganelli C, Alessandri-Bonetti G. Skeletal and dental effects of surgically assisted rapid palatal expansion: a systematic review of randomized controlled trials. Eur J Orthod 2020;42:434-40.
    Pubmed CrossRef