Comparison of traditional RPE with

two types of micro-implant assisted

RPE: CBCT study
Heesoo Oh, Joorok Park, and Manuel O. Lagravere-Vich

Recently, various types of the Micro-implant Assisted RPE (MARPE) were

introduced to obtain greater skeletal expansion and to minimize dental
effects. In the present study, we evaluated skeletal and dental effects immedi-
ately after the completion of expansion using three different types of expand-
ers— a traditional tooth-anchored maxillary expander (TAME) and two different
types of MARPE, bone-anchored maxillary expander (BAME) and tooth-bone-
anchored expander (MSE) using CBCT in adolescents. Overall, the MSE group
showed much greater skeletal changes than the TAME and BAME groups, espe-
cially, at the nasal floor, maxillary base, and palatal suture. About 72
78% of
suture opening was at PNS, which indicates slightly more opening anteriorly
than posteriorly; however, it was relatively parallel in nature than anticipated. In
all three groups, the greatest transverse changes with expansion occurred at the
molar crowns and the 2nd greatest changes at the palatal suture opening at
ANS. It is suggested that MSE can be a great alternative method in correcting
maxillary skeletal transverse deficiency. (Semin Orthod 2019; 25:60–68) © 2019
Elsevier Inc. All rights reserved.

Introduction in the transversal plane increased more anteri-

orly than posteriorly.1 A recent systematic review
R apid palatal expansion (RPE) has been
widely used in correcting maxillary trans-
verse deficiency by separating the two halves of
evaluating 12 relevant articles concluded that
there was no consistent evidence on whether the
midpalatal sutural opening was parallel or fol-
the maxilla at the midpalatal suture to widen the
lowed a triangular pattern.3
maxillary basal bone in children and adolescents.
Since the introduction of temporary anchorage
RPE effects on the facial skeleton and dentition
devices, a bone-anchored expander has been pro-
have been extensively studied in the literature.1,2
posed to obtain greater skeletal expansion and to
Using Bjork’s metal implant method, Krebs
minimize dental effects.4
6 The tooth-anchored
reported that the two halves of the maxilla sepa-
expander (traditional hyrax expander) presum-
rated in a slightly rotary movement, and there-
ably delivers the force to the maxilla through
fore, the effect of expansion on the facial
appliance-supporting teeth. On the other hand, a
skeleton diminishes in the cranial direction;
bone-anchored expander that incorporates tem-
there is a greater increase in width in the lower
porary anchorage devices on the palate delivers
segments than in the upper segments of the max-
the force directly to the maxilla. Various designs
illa in the frontal plane. Furthermore, a rotation
of bone-anchored expanders with or without
attachment to the teeth have been introduced.4
7
Department of Orthodontics, University of the Pacific, Authur A. Some investigators have shown greater skeletal
Dugoni School of Dentistry, San Francisco, CA, United States; effects using micro-implant supported RPE
Department of Dentistry, Faculty of Medicine and Dentistry, Univer- (MARPE). One of the more recent developments
sity of Alberta, Edmonton, Alberta, Canada. of MARPE is a maxillary skeletal expander (MSE),
Corresponding to: 155 5th Street, San Francisco, CA 94103.
E-mail: hoh@pacific.edu
which is a tooth-bone anchored RPE. It is
© 2019 Elsevier Inc. All rights reserved.
designed to produce relatively parallel expansion
1073-8746/12/1801-$30.00/0 by anchoring the posterior part of the palatal
https://doi.org/10.1053/j.sodo.2019.02.007 bone in bi-cortical engagement and has recently

60 Seminars in Orthodontics, Vol 25, No 1, 2019: pp 60
68

 Maxillary expansion CBCT study 61

gained popularity in orthodontics.6 Some investi- inclusion criteria were patients who received one
gators have reported successful parallel skeletal of the three expansion treatments and had two
expansion of the palatal suture using MSE in adult CBCTs before and after the expansion. The
patients that is not limited to the inferior aspect of exclusion criteria were poor image quality and
the nasal cavity, but also extends up to the nasal being equal to or older than 18 years of age.
bone.5,6,8 Table 1 shows the sample distribution for the
With recent increased interest in sleep apnea, three expansion groups.
particular attention has been paid to the skeletal The traditional tooth-anchored maxillary
effects of RPE, such as the possibility of increasing expander (TAME), which is composed of a hyrax
upper airway dimensions through widening of the screw with bands on the first permanent molars
nasal cavity and straightening of the nasal septum, and first premolars, is shown in Fig. 1A. The
which may contribute to the reduction of nasal expansion screw was activated twice a day
resistance and improved nasal breathing.9 (0.25 mm per turn, 0.5 mm daily) until posterior
Recent development of three-dimensional vol- dental crossbite overcorrection (20% more of the
umetric imaging, cone-beam computerized needed correction) was achieved. After active
tomography (CBCT) and 3D reconstruction soft- expansion treatment, a CBCT was obtained (T2)
ware programs allow clinicians and researchers and the screw was fixed with light cured acrylic
to clearly visualize the internal osseous structures and kept in place passively for 6 months.7
and accurately measure changes throughout the For the bone-anchored maxillary expander
basal bone of the maxilla and the adjacent facial (BAME) group, two different bone anchor types
structures.7,10 Thus far, only a few studies besides were used and both types had no direct contact
case reports have been conducted to evaluate to the teeth. The first type composed of 2 cus-
MARPE treatment effects on palatal suture open- tom-milled stainless steel onplants (diameter,
ing and the adjacent facial skeleton. It is a partic- 8 mm; height 3 mm), 2 miniscrews (length,
ular interest of the present paper to evaluate the 12 mm; diameter, 1.5 mm; Straumann GBR-Sys-
magnitude and pattern of the palatal suture tem, Andover, Mass) and an expansion screw
opening and its effects on the adjacent upper (Palex II Extra-Mini Expander, Summit Ortho-
facial skeleton in three-dimension. dontic Services, Munroe Falls, Ohio).7 The other
The purpose of the present study was to quan- type was Dresden-type hyrax expander, which
tify and evaluate the changes that occurred consisted of a temporary anchorage device on
immediately after maxillary skeletal expansion one side and a shortened-implant on the other.11
using three different types of expanders— a tra- The appliances were placed on each side
ditional tooth-anchored RME and two different between the projection of the permanent first
types of MARPE (bone-anchored and tooth- molar and second premolar roots deep into the
bone-anchored) using CBCT in adolescents. palatal vault and 6 mm from the suture. A heal-
ing period of 1 week was allowed before activa-
tion of the expander. With a jackscrew attached
Materials and methods
to skeletal anchors, semi-rapid expansion was
This retrospective study was approved (#17
114) indicated.12 Activation consisted of 1 turn
by the Institutional Review Board of the Univer-
sity of the Pacific. The study sample consisted of
a total of 102 adolescent patients who presented Table 1. Comparison of the Age at T1, time interval
with posterior crossbites and received one of (T2-T1), and sex for three expansion groups
three different types of maxillary expansion BB-RPE TB- RPE MSE
treatment. The sample CBCTs were obtained (n = 37) (n = 41) (n = 24)
from three sources: (1) a previously conducted Mean SD Mean SD Mean SD
randomized clinical trial records from the Uni-
Age at T1 (years) 14.2 1.5 14.01 1.24 13.8 1.9
versity of Alberta; (2) consecutively treated cases T2-T1 (years)* 0.34 0.12 0.24 0.14 0.65 0.57
from a graduate clinic of the orthodontic depart- Sex (M:F) 15:22 14:27 9:15
ment at the university of the Pacific; (3) consecu-
* The time interval (T2-T1) was calculated using time at
tively treated cases from a private orthodontic which records were taken rather than the expansion treat-
clinic located in Los Angeles, CA. The main ment time.
62 Oh et al

(BAME), C. Tooth-bone anchored expander (MSE). (For interpretation of the references to colour in this figure legend, the reader is referred to the web version
Figure 1. Three different maxillary expansion appliances. A. Conventional tooth-anchored maxillary expander (TAME), B. Bone-anchored maxillary expander
(0.25 mm) daily until overcorrection was
achieved. After active expansion treatment, a
CBCT was obtained (T2) and the screw was fixed
with light cured acrylic and kept in place pas-
sively for 6 months.
The subjects in the third group, tooth-bone
anchored MARPE group, received a maxillary
skeletal expander (MSE) developed by Moon
et al.6 (MSE, Biomaterials Korea Inc) (Fig. 1C).
Along with bands on the permanent first
molars, four micro-implants (two on contralat-
eral sides of the midpalatal suture) were placed
on the palate through guide holes in the
expander. The micro-implants were each
1.8 mm in diameter and 11or 13 mm in length,
allowing for bicortical engagement of the
micro-implants at the palatal bone and nasal
floor, which prevented unwanted tipping of the
micro-implants during the expansion.6 The
MSE was activated 0.5 mm daily (0.13 mm per
turn, 4 turns daily) until transverse correction
was achieved, and it is kept in place passively for
6 months. A progress CBCT (T2) was obtained
before removing the appliance. All CBCT
images were taken using the iCAT machine
(Imaging Sciences International, Hatfield, Pa)
with 8.9 s scan time and 21 £ 17 cm or
16 £ 13 cm field of view at resolution of 0.3 mm
voxels. The MSE group patients were collected
from ordinary clinical situations. Therefore, not
all of the second CBCT were taken right after
the completion of the expansion, but rather at
various time intervals ranging from right after
the completion of the expansion to 6 months
after based upon the clinicians’ needs before
removal of the appliances.
For both the TAME and BAME groups, some
CBCT scans were taken using a NewTom 3 G
(Aperio Services, Verona, Italy) at 110 kV, 6.19
mAs, and 8 mm aluminum filtration, while some
scans were taken using the iCAT machine
(Imaging Sciences International, Hatfield, Pa)
with a collimation height scan of 13 cm, scan
time of 20 s, and resolution of 0.3 mm voxel
size.
All DICOM files were imported into the InVivo
6.0 software program (Anatomage, San Jose, CA)
of this article.)

to display the images. The orientation of the volu-

metric images was performed prior to landmark
location by using three reference planes: (1)
Frankfort Horizontal (FH) plane
the primary
reference plane that intersects right porion, left
 Maxillary expansion CBCT study 63

Table 2. Definitions of skeletal and dental landmarks

Landmarks Definition
Landmarks for orientation Nasion (N) Midpoint of the frontonasal suture
Basion (Ba) Most inferior and posterior point at the anterior margin of the fora-
men magnum
Orbitale (Or) Most inferior point along the inferior margin of the orbital rim
Porion (Po) Most superior and lateral point of the external auditory meatus
Bilateral Skeletal Landmarks NF Nasofrontal suture point
FZ Frontozygomatico suture point
ZA Zygomatic arch point-most lateral point of the zygomatic arch
Key Ridge (KR) Most inferior point of the zygomaticomaxillary ridge along the suture
between the zygomatic bone and the maxillary bone
Jugum (J) Intersection of the maxillary tuberosity and the zygomatic buttress in
the frontal view
LN Most lateral point of the anterior piriform apparatus of nasal cavity
IN Most inferior point of the inferior border of the anterior piriform
apparatus of nasal cavity
ANS* Most anterior point of the premaxilla along the midline of the maxilla
PNS* Most posterior point of the palatine bone
Point A* The deepest point on the contour of the maxilla between the anterior
nasal spline and the upper incisor
Bilateral Dental Landmarks U1_M Most mesial point along the upper central incisor incisal edge
U1_D Most distal point along the upper central incisor incisal edge
U1 Apex Upper central incisor root apex
U6 Cr Maxillary first molar mesiobuccal cusp tip
U6 Apex Maxillary first molar mesiobuccal root apex

* Located at both right and left sides at T2.

porion, and right orbitale; (2) Midsagittal plane
bilateral structures. Both the right and left sides of
plane passing through nasion and basion and per- the ANS and PNS points were located to measure
pendicular to FH plane; and (3) Frontal plane
the magnitude of the midpalatal sutural opening
plane perpendicular to both the FH and midsagit- at ANS and PNS at T2. The angular changes of
tal planes and passing through Nasion. Nasion the first molars and central incisors were mea-
point was set as the origin. sured at the internal angle between the long axis
Landmarks were first located on the 3D volu- of the tooth and the FH 3D plane projected on
metric image in which the examiners could freely the frontal plane. The right and left sides were
rotate and crop as necessary for better access and averaged for further data analysis (Fig. 2).
visibility. After the landmark was located on the
volumetric image, its location was simultaneously
Statistical analysis
displayed in the “Slice locator” view, where the
position of the landmark was adjusted in the sagit- Inter-judge reliability for the 16 measurements
tal, coronal and axial views. The dual display of was analyzed using Interclass Correlation (ICC)
the landmark location in the volumetric and cross- and the two judges’ estimates were averaged.
sectional views facilitated a more precise landmark Descriptive statistics were generated to report
identification procedure. Calibration for land- the mean, standard deviation (SD), and range of
mark location was performed by two examiners the demographic information and linear meas-
using randomly selected cases. After satisfactory urements. A paired t-test was performed for com-
calibration sessions, each image was traced by 2 parison between the T1 and T2 stages in each
calibrated examiners and the estimates were aver- group. The mean differences among groups
aged when reporting all measurements. regarding normally distributed parameters were
Table 2 shows the 19 landmarks used in the compared by one-way analysis of variance
present study. A custom 3D cephalometric analy- (ANOVA). When the P-value from the one-way
sis was developed through the Invivo software and ANOVA was statistically significant, a Bon-Fer-
17 measurements were calculated using the roni post-hoc analysis was performed to know
InVivo 3D Analysis tool (Fig. 2). Eleven linear which groups differed from one another. The
transverse changes were measured between the Pearson correlation test was used to identify
64 Oh et al

Figure 2. Skeletal and dental measurements.

correlations between age and the other measure- significant transverse changes were observed. This
ments analyzed. A p-value of 0.05 indicated a sta- finding indicates that all three expansion treat-
tistically significant difference. ments expanded the maxillary dentition and max-
illary basal bone well and minimally affected the
upper facial skeletons that are further away from
Results
the palate. The measurements that did not show
Most measurements had good to excellent inter- statistically significant changes were the bilateral
rater reliability of greater than 0.75 with the nasofrontal suture width (w_NF) for the TAME
exception of w_PNS that had moderate inter-rater and MSE groups and the developing diastema
reliability (ICC of 0.68). Table 3 demonstrates the (w_U1) for the BAME group. The greatest trans-
skeletal and dental transverse changes immedi- verse changes with expansion occurred at the
ately after maxillary expansion. All measurements molar crowns and the 2nd greatest changes
showed highly statistically significant changes occurred at the palatal suture opening at ANS in
(p = 0.01 to p < 0.0001) except for three measure- all three groups. Fig. 3 shows a schematic presen-
ments. Even some of the upper facial sutures sur- tation of the effects of expansion that occurred
rounding the orbit seem to be affected by within MSE group at the different levels of the
maxillary expansion; small but highly statistically facial and dental structures.
 Maxillary expansion CBCT study 65

Table 3. Comparison of skeletal and dental changes between the three groups immediately after maxillary
expansion
BAME (1) TAME (2) MSE (3) p# Pair Comparisons
(n = 36) (n = 41) (n = 24)
x x x
Area of interest Measurement Mean SD p Mean SD p Mean SD p
Skeletal width (mm)
Orbit area w_NF 0.42 0.78 ** 0.06 1.3 NS 0.25 0.81 NS 0.3

w_FZ 0.8 0.89 **** 0.49 0.96 ** 1.15 0.96 **** 0.04 2
3
w_ZA 0.61 0.9 *** 0.68 0.92 **** 1.11 1.12 *** 0.1

Nasal cavity w_LN 0.91 1.1 **** 1.16 1.05 **** 1.38 1.6 *** 0.3

w_IN 1.22 1.7 *** 1.26 1.82 **** 2.66 1.25 **** 0.002 1
3, 2
3
Maxillary base w_KR 1.17 1.89 *** 1.95 1.61 **** 3.61 1.87 **** <0.0001 1
3, 2
3
w_J 2.04 1.86 **** 1.85 1.6 **** 3.75 2.06 **** 0.0002 1
3, 2
3
Palatal suture opening w_ANS 2.87 1.2 **** 3.68 1.24 **** 4.59 1.88 **** <0.0001 1
2, 1
3, 2
3
w_A 2.13 1.29 **** 2.69 1.35 **** 3.95 1.89 **** <0.0001 1
3, 2
3
w_PNS 2.26 1.22 **** 2.83 1.3 **** 3.31 1.39 **** 0.009 1
3,
Dental width (mm)
Maxillary incisors w_U1 0.05 0.47 NS 1.49 1.49 **** 1.79 2.21 *** <0.0001 1
2, 1
3
w_U1Apex 2.21 1.9 **** 2.59 1.87 **** 3.64 2.97 **** 0.05 1
3
Maxillary molars w_U6Cr 3.53 2.07 **** 5.19 2.11 **** 6.33 2.49 **** <0.0001 1
2, 1
3
w_U6Apex 1.8 1.86 **** 1.96 1.89 **** 4.44 1.7 **** <0.0001 1
3, 2
3
Dental angulation (°)
Maxillary incisors U1FrA ¡2.94 2.68 **** ¡1.43 1.83 **** ¡2.3 2.97 ** 0.03 1
2
Maxillary molars U6FrA 2.71 3.26 **** 4.79 3.17 **** 2.9 3.25 *** 0.01 1
2, 2
3
#
One-way ANOVA test.
x
Paired t-test; NS, Not significant; * p<0.05, ** p<0.01, *** p<0.001, ****p<0.0001.

Overall, the MSE group showed much greater root apices increased (2.21 mm) about the same
skeletal changes than the TAME and BAME magnitude as the palatal suture opening at ANS
groups, especially, at the nasal floor, maxillary (2.87 mm). Thus, the incisors’ long axes
base, and palatal suture. Interestingly, the BAME decreased (crowns tipped mesially) by an
and TAME groups showed similar skeletal
changes. Conversely, inter-molar width changes
at the crown level (w_U6) was greater in the
TAME group than the BAME group (5.19 mm vs
3.53 mm, respectively), but there was no differ-
ence in changes at the root apex level for both
the incisors and molars between the TAME and
BAME groups. Thus, greater molar buccal tip-
ping was observed in the TAME group than the
BAME group (4.79° vs 2.71° for each side, respec-
tively). Contribution of skeletal expansion to
inter-molar width increase was evaluated. Since
we did not measure suture opening at the 1st
molar area, we used the suture opening at ANS
as a surrogate measurement for the amount of
skeletal expansion. The greatest skeletal contri-
bution was found in the BAME group, where
almost 81% of inter-molar width increase was
accounted for by skeletal expansion. This was fol-
lowed by the MSE and the TAME groups, with
about 73% and 63% skeletal contribution,
respectively.
Interestingly, in the BAME group, a diastema
between the maxillary central incisors did not Figure 3. Effect of expansion on various areas in the
develop, but the distance between the incisor MSE group.
66 Oh et al

amount that was greater than that of the TAME reported that monocortical mini-implants expe-
group, but similar to that of the MSE groups. rienced significantly greater stress at the bone-
Palatal suture separation was measured using implant interface and more than double the
distances between the right and left ANS, point bending when compared with 2 bicortical mod-
A, and PNS using CBCTs at T2. The greatest els.13 This might be the reason why semi-rapid
suture separation occurred at ANS and suture palatal expansion protocol for the BAME groups
separations at PNS and Point A were slightly less was recommended. However, it is not clear
than that of ANS for all three groups. However, whether this result was derived from either the
the suture opening pattern seemed relatively par- semi-rapid palatal expansion protocol or the
allel in the axial view. The percentage of suture position of the screws and micro-implants that
opening at the PNS relative to ANS was 79% for were placed in the slope of the palatal vault
the BAME group, 77% for the TAME group, and about 6 mm away from the suture between the
72% for the MSE group; no statistical differences permanent first molar and second premolar
were found between the three groups. Fig. 4 roots, or a combination of both.
shows an example of the suture opening patterns We found that the MSE produced much
in CBCTs for each group. The magnitude of greater suture opening and induced less bone
suture opening at all three areas (ANS, PNS and bending and molar buccal tipping when com-
Point A) was significantly greater in the MSE pared to the TAME and BAME groups. The mag-
group than in the TAME and BAME groups, and nitude and pattern of the palatal suture opening
the difference was highly statistically significant were of particular interest in the present study.
(p < 0.0001). We measured suture opening both at ANS and
Some degree of buccal tipping of the molars PNS. Suture opening at PNS was slightly less than
was observed in all three groups, but the greatest at ANS for all three expansion groups. About
amount of tipping (4.79° per side) was observed 72
78% of suture opening was at PNS, which
in the TAME group. Furthermore, in the TAME indicates slightly more opening anteriorly than
group, width changes between the right and left posteriorly; however, it was relatively parallel in
molar apices (1.96 mm) was less than the amount nature than anticipated. This finding supports
of suture opening at PNS (2.83 mm). This may previous studies.2,14 but conflicts with Moon’s
indicates that some alveolar bone bending and report6 using MSE appliance and the study by
uncontrolled tipping of the molars occurred, Christie et al.,15 which found a more parallel pat-
which may have moved the molar root apices tern of suture opening using the TAME. Christie’s
more lingually. study measured suture opening in the middle sec-
tion of the palate from the canine to the first
molar, which did not include either ANS or PNS.
Discussion
In addition, their study sample was young chil-
In this study, we compared the skeletal and den- dren in the mixed dentition.15 These conditions
tal transverse changes immediately after comple- may have contributed to their conclusions that
tion of expansion using a traditional TAME and reported a parallel pattern of suture opening with
two different types of Micro-Implant Assisted the TAME. On the other hand, Moon’s study6
RPE (BAME and MSE). Recently, various used the same MSE appliance that was used in
MARPE designs were introduced, but often con- our study. It is worthwhile to mention that his
tradictory treatment results have often been micro-implant placement seemed to be posi-
reported.6,7 MSE is a particular type of Microim- tioned more posteriorly, immediately anterior to
plant Assisted RPE designed to incorporate the soft palate. He emphasized anchoring the pos-
bicortical engagement of four micro-implants on terior part of the palatal bone in a bicortical man-
the palatal bone.6 The BAME group used a pure ner to produce relatively parallel expansion in
bone-borne RPE type of MARPE that does not adult patients.6 In our study, micro-implants were
apply any force to the dentition. The BAME placed more anteriorly than in Moon’s protocol,
group showed the least amount of palatal suture since the posterior part of the palate gets thinner
opening, but less buccal molar tipping when and often does not provide enough cortical bone
compared to the TAME and MSE groups. The thickness for bicortical engagement in many ado-
most recent Finite element analysis (FEA) study lescent patients. However, it may be feasible to
 Maxillary expansion CBCT study 67

Figure 4. Palatal opening. Examples of CBCT images of the three different maxillary expansion groups at T2. A.
BAME group; B. TAME group; C. MSE group.

place the micro-implants more posteriorly in In all three groups, the greatest transverse
mature patients. With micro-implants in the ante- changes with expansion occurred at the molar
roposterior direction, it seems that rigidity of the crowns and the 2nd greatest changes at the pala-
appliance and position of the expansion screw tal suture opening at ANS. Fig. 3 demonstrated a
could be important factors in deciding the pattern triangular pattern of expansion in the frontal
of suture opening when considering the center of plane, with the greatest increase in the suture,
resistance of the maxilla, which is approximately followed by the maxillary basal bone width
located between the first and second molars in (w_KRG, w_Jugum), and the nasal cavity width.
the sagittal plane.16 Further study is necessary to Previous studies reported similar patterns in the
explore the relationship between position of the expansion of skeletal structures after RPE using
expansion screw and the pattern of sutural open- 3D imaging.10,15 Furthermore, the present study
ing in various age groups. Habersack et al. also found that there are small, but meaningful, statis-
found parallel opening of the midpalatal suture tically significant change that occurred in the
after RPE in a young patient in the mixed denti- orbit area, which includes bilateral frontozygo-
tion.17 In contrast, a 16-year-old patient had pyra- matic suture width. However, almost no changes
midal opening of the suture with jigsaw-like were observed with the frontonasal suture area,
rupture lines indicating greater suture interdigita- which is considered as the center of rotation in
tion.17 However, parallelism of the palatal suture the frontal plane for RPE treatment.
opening has not been fully defined and not Since the expansion forces of the TAME are
strictly applied in the literature. A recent sys- transmitted to the sutures through the teeth, den-
tematic review concluded that expansion tal tipping is unavoidable. Garret et al. reported
through the opening of the palatal suture pro- that dental tipping accounted for 49% of total
gressively becomes more difficult as patients expansion after the expanding with a 4-banded or
get older and results in increased dental 2-banded hyrax appliance in a group of 30 patients
effects.3 In the present study, we found no with a mean age of 13.8 years.18 Our results showed
correlations between age and the magnitude that the least skeletal contribution (63%) was
of suture opening at ANS in adolescent found in the TAME group, whereas the greatest
patients ranging from 10 to 17 years old. It skeletal contribution (81%) was in BAME group.
would be interesting to study whether these It may be advantageous to employ a semi-
findings would hold true in older individuals. rapid palatal expansion protocol when using the
68 Oh et al

BAME since no diastema was developed, but 4. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G.
there was still significant palatal suture opening. Tooth-borne vs bone-borne rapid maxillary expanders in
In addition, minimal buccal tipping of the late adolescence. Angle Orthod. 2015;85:253–262.
5. Choi SH, Shi KK, Cha JY, Park YC, Lee KJ. Nonsurgical min-
molars occurred. Based on these findings, it can iscrew-assisted rapid maxillary expansion results in accept-
be suggested that the MSE appliance using a able stability in young adults. Angle Orthod. 2016;86:713–720.
semi-rapid palatal expansion protocol may be 6. Moon W. Class III treatment by combining facemask
better indicated for growing children whose pala- (FM) and maxillary skeletal expander (MSE). Semin
Orthod. 2018;24:95–107.
tal bones exhibit less resistance than in adults.
7. Lagravere MO, Carey J, Heo G, Toogood RW, Major PW.
Also, more sutural opening can be anticipated Transverse, vertical, and anteroposterior changes from
from placing micro-implants on the palatal roof bone-anchored maxillary expansion vs traditional rapid
with bicortical engagement without risk of touch- maxillary expansion: a randomized clinical trial. Am J
ing the roots. In the present study, we evaluated Orthod Dentofacial Orthop. 2010;137:304.e1
304.e12.
skeletal and dental effects immediately after the 8. Carlson C, Sung J, McComb RW, Machado AW, Moon W.
Microimplant assisted rapid palatal expansion appliance to
completion of expansion. Further study is orthopedically correct transverse maxillary deficiency in
required to evaluate the final treatment out- an adult. Am J Orthod Dentofac Orthop. 2016;149(5):716–728.
comes and stability of these transverse changes. 9. McNamara Jr JA. The role of rapid maxillary expansion in
the promotion of oral and general health. Prog Orthod.
2015;16:33.
Conclusion 10. Ghoneima A, Abdel-Fattah E, Hartsfield J, El-Bedwehi A,
Kamel A, Kula K. Effects of rapid maxillary expansion on
The method of quantitative analysis of changes the cranial and circummaxillary sutures. Am J Orthod Den-
in the transverse dimension using CBCT was tofacial Orthop. 2011;140:510–519.
established in order to investigate and compare 11. Tausche E, Hansen L, Hietschold V, Lagravere MO, Harzer
W. Three-dimensional evaluation of surgically assisted
the various effects of three different maxillary implant bone-borne rapid maxillary expansion: a pilot
expansions on the facial skeletal structures and study. Am J Orthod Dentofacial Orthop. 2007;131:S92–S99.
sutural opening with three different RMEs. For 12. Proffit WR, Fields Jr. HW. Contemporary Orthodontics.
all three groups, the greatest sutural separation Fourth ed. Mosby, Inc.; 2004.
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bicortical mini-implant anchorage on bone-borne palatal
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