Original Article

Skeletal width changes after mini-implant–assisted rapid maxillary

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expansion (MARME) in young adults
Hongyi Tanga; Panpan Liua; Xueye Liua; Yingyue Houa; Wenqian Chena; Liwei Zhanga; Jing Guob

ABSTRACT
Objectives: To observe skeletal width changes after mini-implant–assisted rapid maxillary
expansion (MARME) and determine the possible factors that may affect the postexpansion
changes using cone-beam computed tomography (CBCT) in young adults.
Materials and Methods: Thirty-one patients (mean age 22.14 6 4.76 years) who were treated with
MARME over 1 year were enrolled. Four mini-implants were inserted in the midpalatal region, and
the number of activations ranged from 40 to 60 turns (0.13 per turn). CBCT was performed before
MARME (T0), after activation (T1), and after 1 year of retention (T2). The mean period between T1
and T0 was 6 6 1.9 months and between T2 and T1 was 13 6 2.18 months. A paired t-test was
performed to compare T0, T1, and T2. The correlations between the postexpansion changes and
possible contributing factors were analyzed by Pearson correlation analysis.
Results: The widths increased significantly after T1. After T2, the palatal suture width decreased
from 2.50 mm to 0.75 mm. From T1 to T2, decreases recorded among skeletal variables varied
from 0.13 mm to 0.41 mm. This decrease accounted for 5.75% of the total expansion (2.26 mm) in
nasal width (N-N) and 19.75% at the lateral pterygoid plate. A significant correlation was found
between postexpansion change and palatal cortical bone thickness and inclination of the palatal
plane (ANS-PNS/SN; P , .05).
Conclusions: Expanded skeletal width was generally stable after MARME. However, some
amount of relapse occurred over time. Patients with thicker cortical bone of the palate and/or flatter
palatal planes seemed to demonstrate better stability. (Angle Orthod. 2021;91:301–306.)
KEY WORDS: Maxillary expansion; Mini-implants; Long-term effects

INTRODUCTION
Transverse maxillary deficiency is considered a
The first two authors contributed equally to this study.
common problem,1,2 reported to affect 7.9% of adoles-
a
Lecturer, School and Hospital of Stomatology, Cheeloo cents and nearly 10% of adults.3 This problem is often
College of Medicine, Shandong University & Shandong Provin- associated with a high arched palate, unilateral or
cial Key Laboratory of Oral Tissue Regeneration & Shandong bilateral posterior crossbite, and dental crowding,
Engineering Laboratory for Dental Materials and Oral Tissue which could be underlying factors causing parafunction
Regeneration, Jinan, China.
b
Professor, School and Hospital of Stomatology, Cheeloo of the masticatory system.4,5
College of Medicine, Shandong University & Shandong Provin- Rapid maxillary expansion (RME) is a widely used
cial Key Laboratory of Oral Tissue Regeneration & Shandong and accepted method for the correction of maxillary
Engineering Laboratory for Dental Materials and Oral Tissue constriction in children. However, the fused, mature
Regeneration, Jinan, China.
Corresponding Author: Dr Jing Guo, School and Hospital of
midpalatal suture and adjacent articulations limit the
Stomatology, Cheeloo College of Medicine, Shandong University desired results for nongrowing patients using conven-
& Shandong Provincial Key Laboratory of Oral Tissue Regen- tional RME.6,7 Conventional tooth-anchored RME use
eration & Shandong Engineering Laboratory for Dental Materials could cause dentoalveolar tipping, less skeletal move-
and Oral Tissue Regeneration, Jinan, China, 44-1 Wenhua West ment, and lack of long-term stability.8,9
Road, Jinan, Shandong 250012, China
(e-mail: [email protected]) To reduce possible unwanted side effects, mini-
implant–assisted rapid maxillary expansion (MARME)
Accepted: November 2020. Submitted: May 2020.
Published Online: January 25, 2021 was designed to increase the maxillary width in
Ó 2021 by The EH Angle Education and Research Foundation, nongrowing patients using four mini-implants placed in
Inc. the cortical bone of the palate and nasal floor (NF).10–12

DOI: 10.2319/052920-491.1 301 Angle Orthodontist, Vol 91, No 3, 2021

302 TANG, LIU, LIU, HOU, CHEN, ZHANG, GUO

palatal roof,20 (2) no history of orthodontic treatment

or orthognathic surgery, (3) comprehensive and good-
quality CBCT images, (4) no tooth extraction, and (5)
no severe syndromes such as cleft lip or palate. Three
patients were excluded because of loose mini-screws,

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and the success rate was approximately 92%. In
addition, 12 patients were excluded for having extrac-
Figure 1. (A) Mini-implant assisted rapid maxillary expander tions in the retention phase, thus possibly affecting
(MARME). (B) Jackscrew and four mini-implants were maintained measurements made in the T2 CBCT.
in the palate for retention.

Treatment Protocol
Previous studies found that MARME could produce
more favorable orthopedic and less dentoalveolar A maxillary skeletal expander type II (Biomaterials
side effects as compared with conventional tooth- Korea, Seoul, South Korea; Figure 1A) was designed
borne RME.10,13,14 A study comparing tooth-borne for each patient according to the protocol of Moon et
expanders and bone-borne expanders reported that al.21 Previous studies have reported that digital
the use of bone-borne expansion in the adolescent planning is a successful method for maxillary skeletal
population increased the extent of skeletal changes in expansion.22 The jackscrew was oriented in the
the range of 1.5 to 2.8 times compared with that of midpalatal region between the maxillary first molars
tooth-borne expansion and did not result in any dental and close to the palatal tissue to enable fixation for the
side effects.15 insertion of mini-implants. The length of the mini-
In terms of stability after MARME, Choi et al.16 implants was 11 mm, and the thickness of the
reported skeletal changes and acceptable stability of jackscrew was 2.3 mm, providing a depth of 8.7 mm
MARME using posteroanterior cephalometric records for the insertion of mini-implants. Four mini-implants
and dental casts. More detailed information regarding were inserted along guided slots of the jackscrew.
the skeletal changes might be more appropriately Each had a diameter of 1.5 mm. The jackscrew was
studied using cone-beam computed tomography activated one turn (0.13 mm per turn) per day, and the
(CBCT). In previous studies, hard palate (HP) thick- amount of activation was performed according to the
ness was found to affect the increase in maxillary width amount of maxillary width deficiency of each patient
by MARME,17 and the rigidity of palatal bone was evaluated by CBCT before MARME, ranging from 40 to
reported to be closely related to the width changes.18,19 60 turns. Once the expansion was done, the jackscrew
However, few studies have evaluated the stability of was locked for at least 3 months to stabilize the
skeletal width and factors contributing to stability after expansion.
MARME in adults. After about 3 months of retention, the stainless steel
Therefore, the aim of this study was to observe arms were removed but the jackscrew and four mini-
changes in skeletal width after MARME and investigate implants in the palatal region of the patients were
the possible factors that potentially affected postex- maintained as a passive retainer, and orthodontic
pansion changes using CBCT in young adults. alignment treatment was started. The jackscrew and
four mini-implants were kept in place until the brackets
MATERIALS AND METHODS
were debonded (Figure 1B).
Subjects
CBCT Scan and Measurement
This retrospective study involved 31 young adults
(19 women and 12 men, mean age 22.14 6 4.76 CBCT images were obtained before treatment (T0),
years, range: 18–33 years) who underwent MARME after retention (T1), and after debonding (T2). The
followed by orthodontic treatment at the department of mean period between T1 and T0 was 6 6 1.9 months
orthodontics, Shandong University Dental Hospital, and between T2 and T1 was 13 6 2.18 months. CBCT
from January 2017 to December 2018. Before treat- scans were obtained using a NewTom 5GX-ray
ment, all selected patients were informed regarding the scanner (Quantitative Radiology, Verona, Italy), which
study, and informed consent was signed by each was set at 110 kV and 7.33 Ma while acquiring a total
patient. In addition, ethical approval was obtained from of 538 slices with a 4.8-second scan with an 18 3 16-
the ethics committee of Shandong University Dental cm field of view and a standard voxel size of 0.3 mm.
Hospital (No. 20180102). The digital imaging and communications in medicine
Inclusion criteria were (1) 5 mm or greater of (DICOM) format was imported into Dolphin imaging
maxillomandibular width discrepancy with narrow 11.8 (Chatsworth, Calif).

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MINI-IMPLANT–ASSISTED RAPID MAXILLARY EXPANSION 303

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Figure 2. NF, maxillary width tangent to the nasal floor at its most
inferior level; HP, maxillary width parallel to the lower border of the
CT image and tangent to the hard palate; HP5, maxillary width
parallel to the line NF and 5 mm below the line HP; N-N, nasal width
between the most lateral walls of the nasal cavity; NF10, maxillary
width parallel to the line NF and 10 mm above the line NF; S-S,
posterior midpalatal suture width at the HP level.

The images were reoriented along the palatal suture,

tangent to the nasal floor and parallel to the palatal
plane.23 The skeletal width parameters are shown in
Figures 2 and 3. Then, the measured coronal images
were oriented by the coronal line that was positioned at
the center of the palatal root canal in the most apical
region of the maxillary first molars on the right and left
sides (if the left and right root canal were not at one
coronal line, choosing the midpoint). The possible
factors affecting stability, including palatal bone thick-
ness (PBT), palatal cortical bone thickness (PCBT),
and inclination of the palatal plane (ANS-PNS/SN)
were measured at the midsagittal plane (Figure 4).

Figure 4. Lpt-Lpt, linear distance between the left and right lateral
pterygoid plate measured at the axial slice crossing the palatal plane;
Z-Z, linear distance between the foramina of the left and right
zygomatic bones measured at the axial slice; T-T, linear distance
between the left and right temporal bone measured at the axial slice
crossing the inferior border of joint tubercle.

Statistical Analysis
Two operators performed the measurements, and
intraclass correlation coefficients (ICCs) of Fleiss were
used to check the interobserver reliability. The mea-
sures were repeated after 2 weeks. The method error
was calculated to test the reproducibility of the
measurements.24
Statistical analysis was performed using SPSS
software (version 21.0, Chicago, Ill). The normality of
the data was checked by Shapiro-Wilk test. The means
and standard deviations of the measurements were
calculated, and the paired t-test was used to compare
among T0, T1, and T2. The significance level was
determined as P , .05. Correlations between width
Figure 3. (A) Orientation of coronal image identical to Figure 3. (B)
Orientation of the sagittal image along the midpalatal suture. (C)
changes (T2-T1 relapse) and PBT, PCBT, and ANS-
PBT, palatal bone thickness. (D) PCBT, palatal cortical bone PNS/SN were analyzed using Pearson correlation
thickness. analysis and linear regression analysis.

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304 TANG, LIU, LIU, HOU, CHEN, ZHANG, GUO

Table 1. Descriptive Statistics and Width Comparisons Among T0, T1, and T2
T0 T1 T2 (T1-T2)/
Parameter (Mean 6 SD) (Mean 6 SD) (Mean 6 SD) T1-T0 T2-T1 T2-T0 T1-T0, % PT1-T0 PT2-T1 PT2-T1
NF 68.92 6 5.53 71.25 6 5.70 70.90 6 5.72 2.33 6 1.22 0.35 6 0.33 1.98 6 1.29 15.02 ,.001 ,.001 ,.001
HP 65.53 6 4.93 68.18 6 5.13 67.76 6 5.16 2.65 6 0.98 0.41 6 0.35 2.23 6 1.08 15.47 ,.001 ,.001 ,.001

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HP5 62.28 6 4.32 65.21 6 4.56 64.85 6 4.65 2.94 6 1.32 0.37 6 0.41 2.56 6 1.46 12.59 ,.001 ,.001 ,.001
NF10 80.35 6 8.25 82.63 6 8.23 82.35 6 8.27 2.28 6 1.32 0.27 6 0.33 2.00 6 1.31 11.84 ,.001 ,.001 ,.001
N-N 33.74 6 2.81 36.00 6 2.59 35.86 6 2.55 2.26 6 1.08 0.13 6 0.16 2.12 6 1.08 5.75 ,.001 ,.001 ,.001
Z-Z 103.57 6 5.07 105.02 6 4.89 104.74 6 4.82 1.45 6 1.04 0.28 6 0.32 1.17 6 0.95 19.31 ,.001 ,.001 ,.001
Lpt-Lpt 57.33 6 4.63 58.90 6 4.68 58.59 6 4.60 1.57 6 0.82 0.31 6 0.29 1.26 6 0.89 19.75 ,.001 ,.001 ,.001
T-T 119.13 6 8.37 120.44 6 8.33 120.21 6 8.35 1.31 6 1.04 0.23 6 0.24 1.08 6 1.06 17.56 ,.001 ,.001 ,.001
S-S 0.12 6 0.07 2.50 6 1.41 0.75 6 0.34 2.38 6 1.33 1.75 6 0.37 0.63 6 0.32 * ,.001 ,.001 ,.001

RESULTS DISCUSSION
At T1, all width measurements showed significant After MARME, transverse maxillary deficiencies of
increases (P , .05). The width increases were found in the patients enrolled in this study were resolved, which
a triangular pattern, with the largest increase at HP5 allowed for correction of their malocclusions in three
(2.94 6 1.32 mm) and the least at T-T (1.31 6 1.04 dimensions. Stable increases in skeletal width from T0
mm). to T2 were accomplished, even though a small amount
At T2, decreases observed in the skeletal measures of relapse was noted, comparing T2 to T1. Correlations
varied from 0.13 to 0.41 mm. The smallest rate of between postexpansion changes and palatal cortical
decrease was noted at N-N. The amount of decrease bone thickness and ANS-PNS/SN were observed.
(0.13 mm) accounted for 5.75% of the total expansion Between T0 and T1, significant increases were
(2.26 mm). The largest rate of decrease was 19.75% observed in HP5 (2.94 mm), HP (2.65 mm), NF (2.33
for the lateral pterygoid plate (Lpt-Lpt; Table 1). mm), N-N (2.26 mm), and NF10 (2.28 mm), which
The midpalatal suture width increased significantly described a pyramidal expansion pattern with the
from 0.32 mm at T0 to 2.50 mm at T1 and largest increase near the occlusal level, followed by
subsequently decreased to 0.75 mm at T2. the nasal level, and least in the adjacent bones.25,26 The
In addition, a significant positive correlation was midpalatal suture width of the HP increased from 0.12
observed between PCBT and postexpansion change mm to 2.50 mm on average during expansion.
(T2-T1) in NF, HP, and Lpt-Lpt (P , .05), which Because of the effects on the circumaxillary sutures,
indicated less relapse of expansion width in patients transverse increases were also detected at the
with greater PCBT. A negative correlation was ob- zygomatic bone (Z-Z, 1.45 mm), temporal bone (T-T,
served between postexpansion change (T2-T1) and 1.31 mm), and lateral pterygoid plate (Lpt-Lpt, 1.56
ANS-PNS/SN at NF, HP, and HP5 (P , .05), indicating mm), in agreement with previous studies.27–30
less relapse of expansion width in patients with flatter During the MARME retention phase, the amount of
relapse recorded in the skeletal variables varied from
ANS-PNS/SN (Table 2).
0.13 to 0.41 mm, whereas the midpalatal suture width
The ICC values ranged from .91 to .93, showing
decreased from 2.50 mm to 0.75 mm. The smallest
excellent interobserver reliability. The method error
rate of width decrease was noted at the level of the
varied from 0.09 to 0.20 mm for the measurements.
nasal cavity, namely, a decrease of 0.13 mm, which
accounted for 5.75% of the total expansion (2.26 mm),
Table 2. Pearson Correlation Coefficient Between the indicating that the increase in the nasal cavity was
Postexpansion Changes (T2-T1) and Relative Variables relatively irreversible. Consequently, this could also be
Variable PCBT PBT ANS-PNS/SN associated with an increase in the width of alae nasi,
NF 0.373* 0.269 0.438* which could influence the esthetics of patients by alar
HP 0.429* 0.296 0.534* widening. Therefore, caution in using MARME might be
HP5 0.259 0.221 0.455* warranted in some patients. The largest rate of relapse
NF10 0.302 0.122 0.281
was 19.75% for the lateral pterygoid plate, followed by
N-N 0.027 0.084 0.261
Z-Z 0.005 0.046 0.350 the zygomatic width (19.31%) and temporal width
Lpt-Lpt 0.449* 0.273 0.322 (17.56%). The midpalatal suture width at the HP level
T-T 0.007 0.008 0.321 decreased by 1.75 mm on average from T1 to T2,
S-S 0.328 0.474 0.255 which accounted for 70% of the total expansion (2.50
* Represents a significant correlation, P , .05. mm), whereas the amount of decreased width of HP

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MINI-IMPLANT–ASSISTED RAPID MAXILLARY EXPANSION 305

was only 0.41 mm. It could be speculated that the research funds of the School of Stomatology, Shandong
reduction of the midpalatal suture width might have University (2019QNJJ02).
been mainly derived from bone remolding.
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