How to Cite:

Singh, N., Kaur, S., & Kaur, R. (2021). MARPE: Review of expansion
technique. International Journal of Health Sciences, 5(S2), 86–95.
https://doi.org/10.53730/ijhs.v5nS2.5376

MARPE: Review of Expansion Technique

Navpreet Singh
Department of Orthodontics & Dentofacial Orthopaedics, Desh Bhagat Dental
College & Hospital, Desh Bhagat University, Mandi Gobindgarh, India

Sukhpal Kaur
Department of Orthodontics & Dentofacial Orthopaedics, Desh Bhagat Dental
College & Hospital, Desh Bhagat University, Mandi Gobindgarh, India

Rajdeep Kaur
Department of Orthodontics & Dentofacial Orthopaedics, Desh Bhagat Dental
College & Hospital, Desh Bhagat University, Mandi Gobindgarh, India

Abstract---Contracted maxillary arch has always been a major

concern to those who have interested themselves in regulation of
teeth. Rapid expansion of maxilla by forceful separation has been
discussed in orthodontic literature revealing considerable controversy
over the desire and possibility of splitting the hard palate at the
midsagittal suture as a mean of widening the dental arch and nasal
cavity. Incorporation of mini screws in a conventional RPE appliance
transforms it into a MARPE appliance. Mini screws ensure maximum
skeletal expansion, keeping the dental expansion and resultant side
effects to a minimum. Various designs have been recommended by
authors around the globe; exclusively bone borne, teeth-bone borne
and tissue-bone borne with two/ four mini screws in the assembly.
Paramedian area 3 mm lateral to the suture in 1st premolar region is
considered the most appropriate site for placement of mini screws.
Anterior screws are placed in the rugae area while posterior screws in
the para-midsagittal area.

Keywords---MARPE, expansion technique, skeletal expansion,

paramedian area.

Introduction

Contracted maxillary arch has always been a major concern to those who have
interested themselves in regulation of teeth. Rapid expansion of maxilla by
forceful separation has been discussed in orthodontic literature revealing
considerable controversy over the desire and possibility of splitting the hard

International Journal of Health Sciences ISSN 2550-6978 E-ISSN 2550-696X © 2021.

Corresponding author: Singh, N.; Email: [email protected]
Manuscript submitted: 18 Sept 2021, Manuscript revised: 9 Nov 2021, Accepted for publication: 12 Dec 2021
86
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palate at the midsagittal suture as a mean of widening the dental arch and nasal
cavity1. The first reference to this procedure was that of Angell2 in 1860s. Animal
studies at the University of Illinois followed by clinical studies at his own practice
led Haas1 to report on the increase in nasal width and arch perimeter with
maxillary expansion. Later, it was found that expansion performed after the peak
pubertal growth spurt led to more dental than skeletal changes with side effects of
buccal dental tipping3 and downward and backward rotation of mandible.

Brown introduced the concept of surgically assisted rapid palatal expansion

(SARPE) in 19384, which gradually became main treatment modality for adult
patients with maxillary transverse discrepancy as it helped overcome increased
resistance from bony plates and zygomatic buttress in adults leading to
predictable skeletal and dental changes and low rate of relapse. However, many
adult patients discouraged from choosing this treatment due to invasive nature,
risks, complicationsand cost of the surgical procedure 5. To minimize side effects
of conventional rapid maxillary expansion like alveolar bone dehiscence, buccal
crown tipping, root resorption and marginal bone loss, orthopedic expansion of
basal bone is essential in non-growing patients. To ensure expansion of basal
bone without surgical intervention and to maintain the separated bone in
consolidation, Lee et al6 introduced Miniscrew assisted rapid palatal
expansion(MARPE) and reported successful expansion of maxilla through opening
of mid palatal suture. Incorporation of mini screws in a conventional rapid palatal
expansion appliance transforms it into a miniscrew assisted rapid palatal
appliance7. Three-dimensional finite element studies showed that these devices
had greater skeletal and less dental side effects than traditional rapid maxillary
expanders 8.

Anatomy of palatal suture

It articulates anteriorly with maxilla through transverse palatal sutures and

posteriorly through pterygoid process of the sphenoid bone. The interpalatine
suture joins the two palatine bones at their horizontal plates and continuous as
inter maxillary sutures. These sutures form the junction of three opposing pairs
of bones: the premaxillae, maxilla, and the palatine. The entire forms mid-palatal
suture.Mid Palatine Suture plays a key role in R.M.E. Shape of the suture
throughout life9is variable as: (fig 1)

 Infancy - Y-shape
 Juvenile - T-shape
 Adolescence - Jigsaw puzzle
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Figure 1. Shape of mid palatine suture

As sutural patency is vital to R.M.E, it is important to know when does the suture
closes by synostosis and on an average 5% of suture in closed by age 25 yrs.
Earliest closure occurs in girls aged 15 yrs10. Greater degree of obliteration
occurs posteriorly than anteriorly.

Factors to be considered prior to expansion

Important factors to be considered in Rapid Maxillary Expansion:

 Rate of Expansion: By expanding at the rates of 0.3-0.5mm per day, active
expansion is completed in 2-4 weeks, leaving little time for the cellular
response of osteoclasts and osteoblasts seen in slow expansion.
 Form of Appliance: As the thrust is delivered to the teeth at the inferior free
borders of the maxilla, expansion must reach to the basal portions. The
form of appliance will play an important role in this effort, according to its
rigidity or flexibility, i.e., anchorage or control of tipping.
 Age and Sex of the patient: The increasing rigidity of the facial skeleton with
advancing age restricts bony movements remote from the appliance of
expansion, which differs in both sexes.
 If discrepancy between maxillary and mandibular first molars & bicuspid
width is 4mm or more RME indicated.
 Severity of cross bite i.e., number of teeth involved.
 Initial angulation of molars or premolars: When the maxillary molars are
buccally inclined, conventional expansion will tip them further into the
buccal musculature and if the mandibular molars are lingually inclined, the
buccal movement to upright them will increase the need to widen the upper
arch.
 Assessment of roots of deciduous tooth
 Physical availability of space for expansion.
 Nasal Obstruction: All patients considered for RME should be examined for
nasal obstruction and, if obstruction is found, they should be referred to an
otolaryngologist before orthodontic treatment.
 Medical history: Since the efficacy of maxillary expansion depends on suture
patency and the flexibility of craniofacial complex to adapt to mechanical
changes hence medical conditions altering these should be considered.
 Metabolic disorders: Many metabolic disorders are found associated with
suture synotosis which include hyperthyroidism, hypophosphatemic
vitamin D-resistant rickets, and mucopolysaccharidoses and mucolipidosis.
These disorders are mostly associated with bone metabolism. Maxillary
expansion would be futile even in young patients if they are suffering from
any of these diseases.
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 Periodontal Type: It is essential to record the thickness of the gingival

tissues during clinical evaluation of the periodontium. This is especially
important because a thin and delicate gingiva might be prone to recession
after traumatic, surgical, or inflammatory injuries.
 Mucogingival Health: Orthodontic tooth movement has significant effect on
the mucogingival tissues and hence it is important to assess the periodontal
health of the patient especially before performing maxillary expansion.

Indications of RME

Patients who have lateral discrepancies that result in either unilateral or bilateral
posterior crossbites involving several teeth are candidates for RME.
Anteroposterior discrepancies are cited as reasons to consider RME. For example,
patients with skeletal Class II, Division 1 malocclusions with or without a
posterior crossbite, patients with Class III malocclusions, and patients with
borderline skeletal and pseudo-Class III problems are candidates if they have
maxillary constriction or posterior crossbite. Etiology for maxillary constriction
which indicate RME are:

 Habits-thumb sucking
 Obstructive sleep apnea
 Iatrogenic (cleft repair)
 Palatal dimensions and inheritance
 Muscular
 Syndromes
 Klippel-Feil syndrome
 Cleft lip and palate
 Congenital nasal pyriform aperture stenosis
 Marfan syndrome
 Craniosynostosis (Apert’s, Crouzon’s disease, Carpenter’s)
 Osteopatia striata
 Treacher Collins
 Duchenne muscular dystrophy
 Non-Syndromic palatal synostosis

Biomechanics of miniscrew assisted sutural expansion

Lee et al12 have identified the locations of centres of resistance of dento-maxillary

complex in sagittal and frontal views. When an expansion force F is applied, an
equivalent moment and force result at the centers of resistance of each maxillary
half. The magnitude of the moment is equal to perpendicular distance Y from
respective centers of resistance to the line of action of the expansion force. The
moment equivalent (FY) tends to cause the maxillary halves to rotate about their
respective centers of resistance, while the expansion force F equivalent at the
center of resistance tends to translate the maxillary halves. The net result is to
provide centers of rotation in line with and superior to center of resistance other
than the frontonasal suture.(fig.2)
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Figure 2. Force and moments generated during Expansion

If less tipping and more linear opening of maxillary suture antero-posteriorly is

desired, the fabricated structure joining the sutural opening mechanism to the
teeth would have to be more rigid. By increasing the rigidity of both the sutural
expansion device and the wires joining it to the teeth, the moment induced by the
necessary offsets from the dento-maxillary centers of resistance are reduced or
countervailed, resulting in reduced equivalent moment-to-force ratios at the
centers of resistance13.This causes the center of rotation to migrate superiorly,
reducing the degree of tipping, the center of rotation would migrate further
posteriorly, resulting in a more linear separation of the mid-palatal suture.
Increased rigidity can be obtained by using the largest possible diameter stainless
steel wires and a larger diameter activating screw.

Appliance design

Appliance consists of a central expansion jack screw and four attached arms
soldered to orthodontic bands on anchored teeth with 2 implant or 4 implant
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design to facilitate placement of appliance. Teeth on which bands are soldered aid
in stabilization of jack screw rather than anchorage of appliance as later is
provided by the mini screws inserted into the palate.(fig.3)

Figure 3. Design of appliance

Mini-screw configuration

Dimensions of mini screws as per the design of appliance i.e., 2 implant or 4

implant design. The length of implant chosen should consider height of insertion
slot, space between the appliance and palate, thickness of palatal mucosa and a
desired minimum of 5-7mm of bone engagement. Intention should be to achieve
bi-cortical engagement aiding for better stability of mini screws 14.

Placement of mini-screw

Moon et al evaluated palatal bone density to allow for selection of placement sites
for palatal miniscrews. He suggested that mini screws can be placed successfully
in most palatal areas with equivalent bone densities to that located 3mm
posterior to incisive foramen and 1-5 mm to para median15.(fig.4)

Figure 4. Placement of min screw

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Activation schedule

Dr. Won Moon on his extensive work on MARPE developed protocol for expansion
of maxilla16 as follows:

Biologic response of mid-palatal suture to maxillary expansion

The immediate effect of applying force to the suture results in trauma. Small,
localized tears occurred within the suture from the localized blood vessels. These
small defects are filled with exudate, a few extravasated red blood cells, scattered
filaments of fibrin and a few fine collagen fibrils17. A transient polymorph
response was noted in the region of the defects in the first 12 hours and
thereafter was not seen again. Following the polymorph response, an influx of
macrophages and pioneer fibroblasts into the defect occurred by 24 hours. Within
3 to 4 days, bone formation had begun at the margins of the suture achieved by
the pre-existing and undamaged osteoblasts. These formed successive lamellae
along the suture margin. The collagen fibers and cells are aligned transversely
across the suture corresponding to levels of tension. New bone formation now
occurred along the same axis as trabeculae formed at right angles to the lamellae
deposited initially at the suture margins. With diminution and cessation of the
expansion force (2 to 3 weeks), remodeling of both the bone and the suture
occurred by the osteocytic and fibrocytic cell series until normal sutural
dimensions were achieved. The mineral content within the suture rise rapidly
during the first month after the completion of suture opening. The mineral
content in the bone beside the suture decreased rapidly in the first month but
returned to its initial level within 3 months18.

Effects of RME on maxillary complex

 MAXILLARY HALVES
It is seen that the two halves of the maxilla rotated in both the sagittal and
frontal planes. The maxilla was found to be more frequently displaced
downward and forward1.
 PALATAL VAULT
The palatine processes of the maxilla were lowered because of the outward
tilting of the maxillary halves, also the palatal vault height decreased
significantly during RME. Palatal height returned to pretreatment values
one year after expansion and increased an average of 0.5mm two years after
treatment.
 ALVEOLAR PROCESS
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It has been seen in studies that since bone is resilient, lateral bending of the
alveolar processes occurs early during RME19.
 MAXILLARY ANTERIOR TEETH
From the patient’s point of view, one of the most spectacular changes
accompanying RME is the opening of a diastema between the maxillary
central incisors. It is estimated that during active suture opening, the
incisors separate approximately half the distance the expansion screw has
been opened. Following this separation, the incisor crowns converge and
establish proximal contact. If a diastema is present before treatment, the
original space is either maintained or slightly reduced. The mesial tipping of
the crowns is due to the elastic recoil of the transseptal fibers. Once the
crowns contact, the continued pull of the fibers causes the roots to converge
toward their original axial inclinations.
 MAXILLARY POSTERIOR TEETH
With the initial alveolar bending and compression of the periodontal
ligament, there is a definite change in the long axis of the posterior teeth.
Teeth show buccal tipping and believe to extrude to a limited extent20.
MARPE can be an effective treatment modality for the correction of
maxillary transverse deficiency in young adults through separation of the
mid-palatal suture. Buccal tipping of maxillary teeth upon MARPE leads to
the decrease in buccal alveolar bone thickness and crest height. Attending
orthodontists should pay attention to these changes.

Retention and relapse of RME

Expansion through maxillary suture widening by rapid maxillary expanders has

been claimed to promote stability after retention. Stability has been attributed to
the skeletal component of arch enlargement obtained by the expansion appliance
as opposed to dental expansion as a result of edgewise appliance
mechanotherapy.The causes of Relapse are:

 High stress accumulated between the articulations of the craniofacial

complex.
 Tension produced in the palatal mucosa.
 Imbalance between the buccal and lingual pressures, which is created
because of maxillary expansion.
 The application of a fixed retainer immediately and after rapid maxillary
expansion, then followed by an intermittent removable retention appliance
is highly recommended.

Conclusion

Expansion achieved in the cases treated by MARPE are majorly skeletal

expansion, as the appliance is a tooth-and-tissue borne appliance. It can be used
in young adults from late teens to mid-twenties and exhibits a high success in
this age group.Clinical observations suggest that MARPE prevents many of the
adverse effects of RPE and should be considered as a preferred and effective
alternative for the same 21.
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