Miniscrew Assisted Rapid Palatal Expansion (Marpe) - ExpandingHorizons To Achieve An Optimum in Transverse Dimension A Review

European Journal of Molecular & Clinical Medicine
ISSN 2515-8260 Volume 08, Issue 02, 2021
Miniscrew Assisted Rapid Palatal

Expansion (Marpe) – ExpandingHorizons
To Achieve An Optimum In Transverse
Dimension: A Review
Running title: MARPE- an optimum for transverse expansion
Nishaevitha Kumar1, Asavari Desai2, Supriya Nambiar3, Siddarth Shetty4
1
Resident, Department of Orthodontics, Manipal College of Dental Sciences, Mangalore,
Manipal Academy of Higher Education.
2
Associate Professor,Department of Orthodontics,Manipal College of Dental
Sciences,Mangalore,Manipal Academy of Higher Education.
3
Professor and Head, Department of Orthodontics, Manipal College of Dental
4
Professor,Department of Orthodontics,Manipal College of Dental
ABSTRACT
In recent times, sleep disorders and associated breathing difficulties have received
significant attention, leading to an increased interest in the study of various maxillary
expansion protocols. MARPE has become progressively popular in the management of
transverse discrepancies in comparison to traditional expansion methods, due to its
augmented skeletal effects. Awareness of early prevention or methods to alleviate sleep-
related breathing disorder symptoms by possibly increasing the airway dimensions has led
to an interest in the study of various maxillary expansion protocols. Literature on MARPE,
its effects and techniques are quite scarce. This article aims to review the appliance design,
miniscrew placement, activation technique and post- expansion outcome parameters and
latest advancement in the customized digital manufacturing process.
Key Words: Airway, Expansion effects, Miniscrew-assisted rapid palatal expansion
Abbreviations: MARPE-Mini-implant assisted rapid palatal expansion, RME-Rapid

maxillary expansion, SARPE-Surgically assisted Rapid palatal expansion, MPS – Midpalatal
suture, FEM –Finite element method, MI-Mini-implant.
1. INTRODUCTION
Treatment of the constricted maxillary arch mandates the application of orthopedic forces or
a surgical intervention, for achieving expansion. Patients who have minimal or no growth
remaining are often reluctant to undergo surgery, leading to attempts to correct these
389
deficiencies without subjecting them to surgery, which formed the basis for the development
of MARPE. The MARPE appliance by Dr. Won Moon [8] et al is an innovative modification
of the RME appliance and has evolved as a breakthrough in transverse malocclusion
correction. Since this came into existence, it has proved to be a viable and efficient non-
surgical option for youngadults.
Preoperative Assessment
A thorough clinical evaluation forms the basis for accurate diagnosis of transverse
discrepancies. Model assessment using McNamara [2] and the Andrews WALA ridge[19]
method for assessing intermolar width and upper molar basal arch width respectively can be
helpful in the identification of a true maxillary transverse deficiency when it is not obvious
clinically. McNamara's method of assessment of transpalatal width includes measurement of
the distance between the gingival margin of the lingual groove of 1st molar counterparts on
both sides of the arches. The obtained values are compared with the norms based on the age
to conclude if the maxilla is normal or expansion is required. Andrews WALA ridge focuses
on the mandibular arch which templates the maxillary arch form. The distance between the
mesiolingual cusp tips of right and left maxillary first molars should be equal to the distance
between the mandibular right and left central fossa. Discrepancies in the values obtained
evaluates the need for expansion. Using CBCT, Yonsei’s index. [11] and Case western
reserve university transverse analysis (CWRU) [12] for identification and demarcation of
skeletal constriction and dental compensation can be performed. In Yonsei transverse index
the average difference between the maxillary and the mandibular transverse width at the
estimated center of resistance level was -0.39mm+/- 1.87mm.[11] In CWRU transverse
analysis the measurement of buccolingual inclination of 1stmolars and canines on the
maxillary and mandibular arches are compared with the norms established. Deviations in the
measurements from the norm values indicate transversediscrepancies.
Marpe Appliance Design

Dr Won Moon proposed the original MARPE design [8] which was placed at the centre of
the palate banded to the molars .Later DrKeeJoon Lee modified the design by banding the
first premolars along with first molars. This provided good anchorage and adaptation based
on the topography of the palate for effective separation of the midpalatalsuture.Conventional
Hyrax Rapid Palatal Expander was modified to derive the the Maxillary Skeletal Expanders
or miniscrew assisted rapid palatal expanders by incorporation of miniscrews in the design by
Carlson et al .[8] They claimed that their design produced more of a parallel expansion of
maxillary bone and negligible dental tipping. The changes suggested were Bi-cortical
anchorage of the mini-screws implants, posterior placement of the implants, and reduction in
the rigidity of the connecting wires.[6]
CLINICAL PRESENTATION OF MARPE APPLIANCE [Figure 1]
Based on Lee’s studies, Mac Ginnis[6] et al developed the maxillary skeletal expander (MSE)
with four miniscrews which were placed parallel to the midpalatalsuture.The device had two
390
anterior screws of diameter-1.5-1.8mm, length-11-13mm which could be varied according to

the anatomical thickness of the patient’s palate and two posterior screws of length 9mm. [9]
Modified screw design in MSE— Hex head miniscrews(Medusa, FavAnchorTMSAS, India)
are smooth and less bulky for a secure and precise insertion and are therefore more
comfortable. They are available in 2 sizes - short (2X10mm) and long (2X12mm) based on
requirements.
Two types of activation pin types are made available by Biomaterials Korea.inc,[24]
(1) MSE pintype with a cycle of 4 activation turns of 90° each providing 0.2mm separation
per turn and (2) spanner type of activation key which provides six activation turns per cycle
of 60° each and 0.33mmseparation.[24]
Based on the position of miniscrews and stress distribution various design types are
classified.[Table1].
Insertion Factor Considerations

Appliance position
• Anteriorly-Distal to the 3rdrugae along the anterior palate increases the primary stability due
to thick palatal bone, propagating the forces to the nasomaxillary complex.
• Middle-on the flat palatal but thinner bone surface of second premolar region. This promotes
a close contact area with the jackscrew but significantly increases the risk for bi-
corticalpenetration.
• Posteriorly- immediately anterior to the soft palate, at the region of the first permanent molar.
This results in an increased orthopaedic effect due tothe resistance offered by the
pterygoidplates.
Appliance Insertion
Temporary Anchorage Device (TAD) placement is cumbersome sometimes due to lack
oftorqueanddirectionalcontroltodrivetheimplantintohardpalatalbonewithanengine mounted or
a conventional straight driver. A uniquely designed palatal driver (L’il One,
FavAnchorTMSAS,India)isfavorableinmaintainingthetorqueandangulationforprecise
insertionandplacementofminiscrews.Theclinicalprocedurethatisrecommendedtobe followed is
mentioned in [Table2].
CLINICAL TIPS FORINSERTION

Silicon-based impression material is preferred when impressions are made for obtaining
accurate details which is essential during the digital workflow process. Miniscrews must be
placed before curing the luting cement. A diagonal sequence of miniscrew insertion into the
appliance should be followed. The root status of the supporting teeth on the OPG must be
checked before band placement.
Appliance activation
The activation protocol varies based on the treatment objective and patient biotype.
391
Activation schedule guidelines [Table 4] should be followed for better treatment progress. On
an average, 0.2mm of separation is achieved per turn. Activation is terminated when an edge
to edge contact is achieved between the lingual cusps of maxillary first molars and the buccal
cusps of the mandibular first molar [9].
Activation limits [9] – If the activations exceed the permissible limits, the expander loses
rigidity and undergoes deformation.[Table3].
Recent advances
Ameliorated approach for better activation:-
Patients often require professional support when they are unable to perform expander
activation in certain cases due to increased sutural resistance. This could be overcome by
using an approach of corticopuncture[17] before miniscrew and MARPE insertion.
 Shallow cortical bone is manually predrilled with 1.1mm diameter &4mm bur and contra-
angledscrewdriverpreferablysetin25perminspeed&40Ncmtorquefor corticopunctures, under
greater palatine nerve blockanesthesia.
 Eightcorticopuncturesof5mmdepthalongmidpalatinesuturearemademanually by inserting and
removing a 9mm titanium alloy miniscrew (5mm double thread, 4mm neck of length
&1.8mm diameter.)The distance between 2 perforations should be kept at 2mm.
 Aftertheprocedureprescriptionofanalgesics+0.12%CHXmouthrinsefor7days can begiven.
Recent Advances In The Manufacturing Process Of The Appliance Digital workflow

Customization of the MSE appliances based on the patient-specific characteristics results in a
more precise fit according to the palatal morphology. Virtual planning for the fabrication of
MSE appliances with CBCT derived stereo-lithographic files(.stl files) obtained from
intraoral or dental model scans are superimposed to identify the most suitable anteroposterior
and vertical positioning of the appliance based on the extentand thickness of the palatal vault
by evaluation of parameters in the sagittal, coronal and axial views. [22,23] Qualitative
assessment of bone is not possible with CBCTderived
.stl file so a CBCT DICOM file can be used for qualitative and quantitative bone assessment
for ensuring primary stability and reliable anchorage.
During superimposition, miniscrews are virtually inserted facilitated by tailored surgical
guides(obtained from the patient directly if required) or direct virtual planning using specific
reference planes of CBCT midfacial skeletal landmarks is done based on the most suitable
angulation and precise directional positioning using appropriate CAD software.[22,23] A
single consolidated .stl file representing the negative template of MSE palatal expander is
created from which the final lab template is fabricated after subtraction from the 3d model
designed using dolphin software .[10] A trial check for the fit of the MSE 3D model on the
patient’s palatal topography can then be done followed by designing of the final appliance by
placing the MSE within the template on the printed model.
392
Post expansion assessment

Skeletal and dental effects
The total expansion achieved is a combination of skeletal (orthopedic) expansion and
dentoalveolar (orthodontic) expansion which includes the alveolar bone bending and dental
tipping.
In conventional hybrid bone-borne RPE appliances, center of rotation of maxilla is much
higher than the miniscrew placement position, leading to torque generation in two maxillae
resulting in alveolar bone bending.[6] Though the relative position of anchored teeth was not
changed dental tipping could be observed due to alveolar bone bending. By exerting the
expansion forces pointing closer to the maxilla's center of resistance, a more lateral
translation of the complex could be achieved with reduced dental tipping.
Since the greatest resistance against sutural opening is the pterygomaxillary complex, the
body of MARPE should be positioned close to the junction of hard and soft palate.[6]
If the forces are applied to the center of resistance of maxilla through appropriate
microimplant positioning using customized MARPE appliances, the force system becomes
more favorable which would practically eliminate the inclined forces due to homogenous
force dissipation on the posterior teeth facilitating more parallel midpalatalsutural opening
coronally. Pterygoid plate separation with MARPE results in a parallel expansion in
comparison to SARPE which gives a ”V” expansion, as there is an absence of pterygoid plate
separation at the mid palatal suture.[14] Bony resistance of maxillary expansion would be
less in children and adolescents as their pterygomaxillary and zygomaticomaxillary sutures
are less matured. In adult patients due to greater bony resistance offered, a substantial amount
of orthopedic force will be experienced on the anchor teeth too resulting in dental tipping and
alveolar bone bending.
The zygomatic bone shows a forward and lateral displacement. The forward
displacement is minimal as a whole, whereas the lateral displacement is more near the
zygomaticomaxillary suture and gradually decreases towards the temporal process of the
zygomatic bone (zygomatic arch) and further decreases towards the frontozygomatic suture.
Overall the zygoma rotates along with the zygomaticomaxillary complex with the
frontozygomatic suture as the fulcrum. Cantarella et al [13,15,16] states that there could be
almost no displacement that could be seen above the frontozygomatic suture and a possibility
for asymmetric expansion due to differences in densities and morphology of bones especially
the zygomatic buttress and pyramidal process which may not be identical on both sides. He
suggested that the fulcrum of rotation of the maxilla to be more posterior and lateral in
MARPE when compared to the tooth-borne appliance. Since the maxilla is located medially
and anteriorly to this fulcrum of rotation, during expansion the maxilla tends to move
laterally and anteriorly. This movement further helps in the disarticulation of pterygopalatine
sutures. The pterygoid fossa and the infratemporal surface show almost no displacement.
Stress distribution as per FEM studies:-

Use of FEM to work out the strain distribution and displacement within the craniofacial
complex in MARPE concluded that in contrast to standard expansion methods, MARPE
showed less propagation of stress to the buttresses in comparison to adjacent locations within
393
the maxillary complex. [6] The maximum Von Misses stress was seen in the implant-
supported region and it reduces along the connecting arms, almost disappearing as it reaches
the outer end of the bands. Reducing the stress around the cervical region of the bone-implant
interface by bi-cortical engagement will reduce the risk of implantfailure.
Higher stress levels were witnessed within the canine and molar regions of the maxilla,
lateral wall of the inferior nasal cavity, zygomatic, and nasal bones.The greatest stress
concentration is observed at the pterygoid plates of the sphenoid bone near the cranial base.
Some amount of buccal tipping is inevitable due to the usage of teeth as anchor units
alongside MI in MARPE appliances but very much reduced in comparison to conventional
appliances as reported by Greug and Garib et al. Due to increased density of the buccal
cortical bone in the maxillary canine and premolar regions, greater buccal tipping of first
molars occurs when compared to the first premolars.[6]
Jafari et al [3] found that the inferior part (the free ends) of the lateral pterygoid plates bent
laterally and diminished in the regions which were closer to the cranial base. No
displacements were evident on the rest of the sphenoid bone.
Respiratory Airway Effects

Studies explain that orthopedic expansion by resolving the nasomaxillary deficiency
also alters the abnormal breathing pattern. [7] Post -MARPE patients incline more towards
nasal breathing thereby probably altering the tongue posture and muscular dynamics,
indirectly increasing the nasopharyngeal airway which further enhances expiratory peak flow.
[14 ]Nasal inspiratory peak flow, an indicator for nasal and oral obstruction, can be increased
immediately after expansion with stability maintained up to 5 months. [14] The zygomatic
arch is expanded to a lesser extent than the nasal cavity which substantiates the increased
nasal airflow creating a positive impact on respiratory function and muscle strength. The
increase in airway volume was
greater than conventional RME. MARPE treatment with an efficient increase in the nasal
cavity volume also improves the constricted airway and the upper airway resistance, thus
aiding in the long-term stability of the corrected malocclusion. No implicit difference in
oropharyngeal and hypopharyngeal airflow improvement was recorded in the literature.
Separation is effected in the nasal area and causes a sudden improvement in the airflow by
relieving the obstruction causing nasal air resistance,thus an aid in mouthbreathers.
Advantages of MARPE
Treatment duration is very less, one to four weeks of active expansion period, when
compared to other conventional expansion, 2-6 months of period for expansion. MARPE
independent of any anchor teeth units supports a simultaneous fixed orthodontic therapy and
expansion as an added advantage. Maximal skeletal displacement can be achieved with
minimal dental tipping effects. More stable on completion of treatment because the maxillary
posterior teeth are not tipped buccally as much as in conventional expansionprocedures.
394
Limitations of MARPE:-
 Forces applied from increased distance to the bone or implant interface leads to higher
chances of MI deformation. [9]
 ChanceoftreatmentsuccessishinderedwhenMSEisplacementisattemptedon a narrow high
archedpalate.
 Unpredictable variability in the pattern of MPS calcification and craniofacial architecture
(higher resistance) are contributing factors for MARPEfailure.
 Incorporation of Missing/compromised anchor units in classic design MARPE
implementation is ahindrance.
 MARPE creates stress distribution around the anchor teeth and zygomaticomaxillary process
extending along the external wall of the orbit, which can cause dizziness and tension around
the bridge of the nose, eyes, and mostly throughout the face. Therefore in individuals who
have very heavy sutural inter-
digitationandbonedensityexpansionmustresorttosurgicallyassistedexpansion.
 Incaseofmultiplecongenitallymissingteethanoftenassociatedwithcraniofacial anomalies sutural

expansion is difficult due to loss of anchorage. The use of endosseous implants as abutments
for sutural expansion would eliminate unwanted tooth movement and may allow non-surgical
treatment in cases with a compromiseddentition.
Indications for MARPE

MARPE has effects on respiration and as well as on the occlusion. The separate assessment
of both respiration and occlusion in majority of patients show that both were mutually
supporting one another e.g. buccal cross bite are associated with increase in nasal resistance
and mouth breathing.
Based on Occlusion
 Maxillary deficiency is Class III Cases: MARPE is of value in the Class III malocclusions
with maxillary deficiency and also with flattened profile in the middle third of the
face,crowding of maxillary arch and cross bite which maybe either unilateral or bilateral and
the teeth are often inclinedbuccally.
 Bilateral or severe unilateral expansion in class I cases: Conventional forms of orthodontic
treatment takes a long period for correction and relapse following treatment. Rapid expansion
with MARPE corrects the relationship of thebuccal segments within 3 weeks without fitting
the teeth in to an unfavourable relationship .There may be a forward movement of the upper
incisors in these and teeth should not be included in the appliances .This allows them to
relapse back into correct relationship with the lower teeth during the period of stabilization.
 Certain Class 2 div 1 malocclusion cases which in which there is an extreme narrowing of the
upper arch associated with a unilateral or bilateral crossbite.
 Selected arch length discrepancy cases: Borderline case with goodfacial patterns.
 True maxillary deficiency case: Cases in which mandible is normal with under developed
maxilla with a straight profile in a midface region and are also associated with crossbite.
 Relative Maxillary deficiency case: A case in which a larger size of mandiblewith a
395
normalmaxilla.
 Asymmetries of condylar position: Skeletal response during MARPE redirectsthe developing
posterior teeth into normal occlusion and corrects asymmetries of condylar functional shifts
and possible temporomandibular jointdysfunction.
 Class II cases with mouth breathing : A narrow nasal aperture literally filled by concha, with
deviated nasal septum ,is often seen in these patientsincreasing the internasal capacity to
facilitate nasalrespiration
Medical Indications:
 As a preliminary to septoplasty
 Nocturnal enuresis: Sleep laboratory confirms the etiology of nocturnal enuresis due to
disturbed sleep patterns by obstruction, which is usually caused by an adenoidal hypertrophy
or less commonly, an anterior nasal stenosis. Considering MARPE as a most successful
procedure in early adult dentition,maxillary expansion in nocturnal enuresis cases of young
adults can reduce the adenoids in a fewmonths.
Contraindications of MARPE:
 A person who shows soft tissue pathology in pressure bearingareas.
 Patient with severe tendency to gingival enlargement as in Dilantoinhyperplasia.
 Patient with cover bite(maxillary teeth completely outside themandible)
 Patient with normal buccal occlusion in lateralaspect.
 Patients who cannot co-operate with theclinician.
 Patients with severe anteroposterior and vertical skeletaldiscrepancies.
 Patient with single teeth cross bite, anterior open bite, steep mandibularplanes and
convexprofiles.
 Patient with skeletal asymmetry of maxilla ormandible.
2. CONCLUSION:-
MARPE has proved to be an effective and viable procedure for the correction of
transverse maxillary deficiency offering a significant success rate and stability.MARPE is
claimed to be more efficacious than conventional RPE and had also subjugated SARPE as an
acceptable and cost-effective alternative in suitable cases.
TABLE 1: MSE Design types (Bone -borne)

DESIGN TYPE MINISCREW STRESS DISTRIBUTION
PLACEMENT
TYPE 1 Lateral to midpalatal suture Concentratedaround

miniscrews andMPS
TYPE 2 At the palatal slope Low stresses evenly

around the implants
396
TYPE 3 As in type 1 with additional Largely on the MPS and

conventional Hyrax arms around micro-implants and
anchor teeth roots.
TABLE 2: Clinical procedure:-

VISIT CLINICALPROCEDURE LABORATORY
[9] PROCEDURE
1st Separator placement on maxillary

permanent 1 st
molars
2 nd 1) Separators are removed followed by 2) Alginate impression is made

band placement on 1stmolars after and poured with regular
prophylaxis. plaster.
3) After the replacement of separators 4) Selected MSE is soldered to
orthodontic accessories can be bands according to curvature
of the palate with 2mm
separation from the palate.
397
soldered to the bands at this stage. 5) Reverse traction screws are

soldered (optional) on the buccal
aspect of molar bands followed
by finishing
and polishing.
3 rd • Separators are removed and expander

proof is placed after prophylaxis.
Appliance cementation is done under
topical anesthesia after vertical
positional assessment.
• Self -drilling mini- implants are placed
under local infiltrative anesthesia.
• Immediate expander activation is done
using the appropriate digital key.
• Hygiene and activation instructions
with optionalanalgesic
drug prescription for
398
2 days should be given.

• Antibiotic coverage for good general
health may notbe
required.
Follow up • MI stability is checked with

tweezersregularly.
• The distance of the expander from
mucosa is checked at allvisits.
• If the mobility of MI is witnessed,
treatment can still be continued
carefully with one properMI
on each side.
Removal • Removal is done by counterclockwise Removed MI should be

rotation of jackscrew with the discarded without sterilization
digitalkey and reuse
• Hydrogen peroxide dipped cotton
pellet on MI removed site to
promoteasepsis.
• Oral Prophylaxis before removal is
attempted toprevent
Plaqueaccumulation
399
on MI head hinders
MI gripping.
TABLE 3: ACTIVATION LIMITS

MSE size MAXIMUM
NUMBER OF ACTIVATIONS
8mm 40
10mm 50
12mm 60
TABLE:4 ACTIVATION SCHEDULE [9]

AGE GROUP INITIAL EXPANSION RATE EXPANSION AFTER OPENING
MPS (DIASTEMA
FORMATION)
Beginning of 3-4 turns /week 3 turns/week

adolescence(13- 16
years)
400
End of 1 turn / day 1 turn/ day

adolescence(16- 19
years)
Young adults(19- 2 turns per day 1 turn/ day

25
years)
Adults(Older 2 or more turns per day 1 turn/ day

than 25 years)
(ADOPTED [9])
Figure
401
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ISSN 2515-8260 Volume 08, Issue 02, 2021