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Effectiveness of miniscrew assisted rapid palatal expansion (MARPE) using
cone beam computed tomography: systematic review and meta-analysis
Article in The Korean Journal of Orthodontics · March 2022
DOI: 10.4041/kjod21.256
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Title Page
Effectiveness of miniscrew assisted rapid palatal expansion (MARPE) using
cone beam computed tomography: systematic review and meta-analysis
Patchaya Siddhisaributr, Kornkanok Khlongwanitchakul, Niwat Anuwongnukroh,
Somchai Manopatanakul, Nita Viwattanatipa
Faculty of Dentistry, Mahidol University, Thailand
a. Dr. Patchaya Siddhisaributr
DDS.
Resident of Orthodontics, Faculty of Dentistry, Mahidol University,Thailand
Email: [email protected]
ORCID: 0000-0001-7317-4149
b Dr. Kornkanok Khlongwanitchakul
DDS.
Resident of Orthodontics, Mahidol University, Thailand
Email: [email protected]
ORCID: 0000-0002-8199-6537
c. Clinical Professor Niwat Anuwongnukroh
DDS., M.S.D.(Orthodontics),
Diplomate Thai Board of Orthodontics,
Diplomate American Board of Orthodontics
Department of Orthodontics, Mahidol University, Thailand
Email: [email protected]
ORCID: 0000-0002-7104-4778
d. Associate Professor Somchai Manopattanakul
DDS. (2nd class honors), Grad. Dip. (Periodontology),
MD.Sc (Orthodontics), Diplomate, Australian Board of Orthodontics,
Diplomate, Thai Board of Orthodontics
Department of Advanced General Dentistry, Mahidol University, Thailand
Email: [email protected]
ORCID: 0000-0002-6771-2243
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d. Associate Professor Nita Viwattanatipa
DDS., Cert., MSD.(orthodontics),
Diplomate ABO , Diplomate ThBO
Department of Orthodontics, Mahidol University, Thailand
E-mail: [email protected]
ORCID 0000-0001-9557-7539
Corresponding author:Assoc. Prof. Nita Viwattanatipa,
Department of Orthodontics, Mahidol University, Bangkok, Thailand 10400
E-mail: [email protected]
Tel: 66-86-4008716
ACKNOWLEDGEMENTS
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Authors would like to acknowledge Faculty of Dentistry, Mahidol University for
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research funding support.
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Effectiveness of miniscrew assisted rapid palatal expansion (MARPE) using
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cone beam computed tomography studies: systematic review and meta-
3
analysis
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5
Abstract
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Objective:
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This systematic review and meta-analysis aims to examine the treatment
8
effectiveness of MARPE in late adolescents and adult patients using cone beam
9
computed tomography studies (CBCT).
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Methods: Literature search based on PICOS keyword design focusing on MARPE
11
was conducted in 5 electronic databases (Pubmed, Embase, Scopus, Web of
12
Science and Cochrane Library). Out of 18 CBCT outcomes screened, only 9
13
parameters were sufficient for the quantitative meta-analysis. The parameters were
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classified in 3 main groups which were; 1) skeletal change (5 parameters), 2)
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alveolar change (1 parameter) and 3) dental change (3 parameters). Heterogeneity
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test, estimation of pooled means publication bias, sensitivity analysis and risk of
17
bias assessment were performed.
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Results:
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Database searching found 364 results but only 14 full-text articles were qualified.
20
Heterogeneity test indicated the use of random-effects model. The pooled mean
21
estimate were as follows; 1) Skeletal expansion: zygomatic width 2.39 mm, nasal
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width 2.68 mm, jugular width 3.12 mm, midpalatal suture at PNS 3.34 mm and at
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ANS 4.56 mm, 2) Alveolar molar width expansion 4.80 mm 3) Dental expansion:
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inter-canine width 3.96 mm, inter-premolar width 5.22 mm and inter-molar width
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5.99 mm. Percentage of expansion showed the effect at skeletal expansion (PNS)
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was 55.76%, alveolar molar width expansion 24.37% and dental expansion
4
1
19.87%. Limitation of study involved the quality of papers which mostly were one-
2
group pretest-posttest design.
3
Conclusions:
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In coronal view, MARPE created skeletal and dental expansion as pyramidal
5
pattern. MARPE could successfully expand the constricted maxilla in late
6
adolescents to adult patients.
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Keywords: Evidence-based orthodontics, Appliances, MARPE, MSE
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1
INTRODUCTION
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A unilateral or bilateral posterior crossbite, or maxillary transverse
3
deficiency (MTD), are malocclusion frequently found in orthodontic treatment.
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Other discrepancies associated with MTD may involve skeletal, dento-alveolar,
5
soft tissue and function, for example, class II or class III skeletal mal-relationship,
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excessive vertical alveolar height, functional shift of the mandible, crowding,
7
bucco-lingual tipping of posterior teeth etc.1
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MTD does not show spontaneous correction and should be treated with
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maxillary expansion as early as possible.2 Generally, the optimal timing for MTD
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correction with conventional rapid palatal expander (RPE) is preferably below the
12
age of 15.3 Unfortunately, in late adolescents and adults, the midpalatal suture and
13
nearby maxillary sutures start to fuse and become more rigid, leading to a higher
14
resistance to expansion force.4 Thus, the nonsurgical conventional RPE would be
15
less successful in adult patients and may lead to undesired complications such as
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buccal crown tipping of posterior teeth, pain, tissue swelling, root resorption,
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marginal bone loss, gingival recession, limited skeletal expansion, failure and post-
18
expansion relapse.5
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Therefore, in adults or from the age of 16 onwards, surgically-assisted RPE
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(SARPE), is commonly recommended. However, the invasiveness of this surgical
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procedure, the inherent risks of surgical operation, expensive cost, the
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hospitalization, etc may pose limitations for patients to undergo this procedure.1,6
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Recently, a novel non-surgical treatment of MTD in adults, using miniscrew
assisted rapid palatal expansion (MARPE), is considered a possible alternative for
6
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SARPE. It could also be named as microimplant assisted rapid maxillary
2
expansion (MARME) or maxillary skeletal expansion (MSE).7 The device could be
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classified mainly as; 1) bone-anchored maxillary expander (BAME) which is the
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bone-borne type which has no tooth attachment and 2) hybrid design or tooth-
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bone-anchored maxillary expander which combined both bone and tooth support.8,9
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Another classification could be either mono-cortical or bi-cortical miniscrew
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anchorage.10,11 MARPE may be consisted of either 2 to 4 miniscrews, with or
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without extension arms to the first premolars. One of the most well-known
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commercial expander, the so called MSE is the appliance which promotes bi-
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cortical engagement of the four miniscrews into the cortical bone of palate and
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nasal floor.12
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Recent clinical studies using MARPE found a high success rate of the
14
midpalatal suture separation in young adults which could range from 71-
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92%.1,7,8,13,14 Nevertheless, failure of the midpalatal suture separation and
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incidents of asymmetric expansion were reported in some cases.8
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In adult, several research papers showed that MARPE could make the
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transverse expansion of midpalatal suture, zygomatic bone, temporal bone, lateral
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pterygoid plate and nasal cavity at varied extent.7,15 The expansion of the maxilla
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was as a pyramidal pattern with the least expansion at the level of zygoma then
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progressively increased across palate to the greatest expansion at dental level.8
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The pattern of midpalatal suture separation by MARPE was different from
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that of conventional RPE. While RPE made more opening in the anterior than the
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posterior palate, majority of MARPE studies reported that it created the parallel
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split pattern of midpalatal suture.8,12,13,16,17 Moreover, MARPE could create the
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openings between the medial and lateral pterygoid plates without any surgery. The
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pterygo-palatine suture splitting or the pterygo-maxillary dysjunction was
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detectable in 53% - 84% of the sutures.16,17
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Although there were several studies evaluating the skeletal and dental
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response of MARPE in adults, its treatment effects still remained controversial.
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Most of these publications were retrospective with limited sample size.1,8,14,15,18,19
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Only two studies were prospective study.20,21 Recently, there were two papers
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which compared the effectiveness between MARPE and SARPE in late
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adolescents and adults which reported that MARPE had similar effectiveness with
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SARPE, but with the less complications.13,22 To our knowledge, there has been no
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randomized controlled trial RCT) publications at present. Thus, both orthodontists
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and oral-maxillofacial surgeons are interested to see the more concrete evidence of
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MARPE effectiveness which is the rationale of our study.
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The research question of our systematic review and meta-analysis study
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aims to answer about the treatment effect of MARPE, with specific purpose to
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summarize the treatment outcomes of MARPE in adult patients in the context of
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skeletal, alveolar and dental changes using CBCT evaluation.
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MATERIALS AND METHODS
This meta-analysis was based on the Preferred Reporting Items for
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Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines. The
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study protocol was granted with Prospero registration number CRD42021255630.
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Eligibility criteria
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The PICOS framework was used to construct the inclusion criteria as shown
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in Table 1.
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Search strategy
5 Electronic databases (Pubmed, Embase, Scopus, Web of Science and
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Cochrane library) were systematically searched up to June 2021. No limits were
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applied for language or publication date. Dissertations and conference proceedings
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retrieved from electronic database were also included. In addition, secondary
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search from reference lists of systematic review and meta-analyses articles were
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manually examined and any papers of interest by title or author were retrieved for
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possible inclusion. Details of advanced search keywords are given in Appendix 1.
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Duplicated records were deleted using EndNote® 9 (Clarivate Analytics,
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USA). Title and abstract of all identified articles were independent reviewed by 2
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reviewers (PS and KK) according to inclusion/exclusion criteria, in a blinded
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standardized manner. Disagreement between reviewers were resolved by
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discussion with a third researcher (NV).
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Data collection
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Full text papers were retrieved after title and abstract screening. Two
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reviewers independently extracted the data from relevant studies according to full
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1
text eligibility criteria, and then recorded into the data extraction spreadsheet. The
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extracted data characteristics included the author, year of publication, sample size,
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study design, setting, race, comparison groups, appliance, diameter and length of
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miniscrew, mean age and SD in years, activation protocol and success rate.
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Because the CBCT outcomes reported in literatures were varied greatly
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among studies, preliminary screening was necessary to check adequacy of the
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numbers of papers for each value. Overall,18 skeletal, alveolar and dental
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parameters were screened, however, only 9 parameters were sufficient for the
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subsequent quantitative analysis. The eligible outcomes were as follows.
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- Skeletal expansion: zygomatic width, nasal width, jugular width, midpalatal
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suture at PNS and ANS.
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- Alveolar expansion: alveolar molar width.
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- Dental expansion: inter-canine width, inter-premolar width and inter-molar width.
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Calculation of any raw data that needs the combined means was carried out
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with the online application using the sample size, means and standard deviations in
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order to obtain the new values.
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Meta-analysis
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Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)
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Forest plots would be shown as visual assessment of heterogeneity across
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studies. Statistical heterogeneity was assessed by Cochrane Q-test at 95%
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confidence (p-value < 0.05). Moreover, the I2 statistics were used to assess the
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degree of heterogeneity. The I2 index was defined as low (25%), moderate (50%),
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or high (75%). If I2 was more than 50%, significant heterogeneity would be
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1
considered and random effect would be used to estimate the pooled means with
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95% CI. Otherwise, fixed effect model would be used.
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Publication bias (Funnel plot and Egger’s test)
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In addition, publication bias was tested by funnel plot and Egger’s test. If the
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distribution was equal between each side of funnel plot, this meant that there was
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no publication bias. However, if small studies clustered asymmetrically around the
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pooled mean estimate line, this would indicate the bias of study.
The Egger’s test was used to evaluate the symmetry of funnel plot.
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If it was significant (p value < 0.05), there might be publication bias due to missing
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studies or heterogeneity.
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Sensitivity analysis
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The sensitivity test would be performed if there was any studies that were
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considered as poor quality or being a source of publication bias. The method trim
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and fill procedure by Duval and Tweedie. would be used to correct publication bias
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by imputing hypothesized missing studies for the new adjusted pooled-mean
18
estimate. In order to err on the safe side, the sensitivity analysis would also be
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attempted if there was any case that was insignificant but with p-value closed to
20
0.05.
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Subgroup analysis
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If the possible causes of results variation were detected across studies, subgroup
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analysis would be performed.
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.
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Risk of bias assessment in individual studies
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1
Risk of bias in individual studies was assessed both at the methodology and
2
outcome level by two reviewers. The criteria was modified from the method
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reported by Feldmann and Bondemark.23 The assessment included study design,
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sample size, selection description, measurement method, method error analysis,
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blinding in measurement, statistic method and confounding factors.
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RESULTS
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Search strategy
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The PRISMA flow diagram demonstrating the search and selection of
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studies is shown in Figure 1. The initial 364 results were from 5 database as
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follows: 84 from Pubmed, 81 from Embase, 97 from Scopus, 83 from Web of
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science and 19 from Cochrane library. Through manual searching, 1 article was
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found from google scholar. The remaining 149 articles were screened based on the
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titles and abstracts. Inter-reviewer agreement on study eligibility was 96% (6/149).
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After abstract screening, 29 articles met the inclusion criteria. Then, full text were
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examined. The remaining 15 studies were used in quantitative analysis. However,
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since there were 2 studies by Oliviera et al.13 which may use the same group of
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subjects, only one study with most recent information was selected to prevent
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double-counting data. Finally, 14 studies were eligible for meta-analysis.
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Study characteristics
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Characteristics of each study is shown in Table 2. Ten were retrospective
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one-group pretest-posttest design studies.7,11,15,16,18,24-28 Three were retrospective
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cohort studies,13,22,29 and one was the prospective study 20
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The sample size ranged from 8 to 48 patients. Regarding the appliance
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1
design, 2 studies used modified Hyrax II with extension to first premolars,1,15 3
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studies used PecLab appliance (Brazil), 9 studies used BioMaterials (Korea). The
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device of all studies incorporated 4 titanium miniscrews with diameter of either 1.5
4
or 1.8 mm. It should be noted that majority of studies used miniscrews with the
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length of 11 mm except 2 studies used 7 mm length.1,15 The mean age of most
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studies was late adolescents to adult patients. The success rate of midpalatal split
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ranged from 84% to 100%, however, half of the studies did not report this data.
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Meta-analysis
Outcomes of CBCT measurement from final recruited papers for skeletal
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expansion are shown in table III. Alveolar molar width and dental expansion are
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shown in table IV.
13
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Heterogeneity test (Forest plots, Cochrane Q-test, and I2 index)
15
The forest plots of skeletal, alveolar molar width and dental expansion are
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shown in figure 2, 3 and 4 respectively. The vertical line of diagram indicates the
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point estimate of means and the horizontal line shows the 95% CI.
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According to table 5, the heterogeneity test indicated that the Q-values of all
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variables were statistically significant (p-value < 0.05). Similarly, the I2 index of
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all variables are high (>50%). Therefore, random effect model was used.
21
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Estimation of pooled means with 95% confident interval
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Pooled mean estimate with 95% confident interval of skeletal change
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is shown in Table 6 and figure 2. Alveolar change is shown in Table 6 and
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figure 3. Dental change is shown in Table 6 and figure 4.
13
1
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Publication bias
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Visual inspection of data distribution around funnel plots of all
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parameters are shown in figure 5. In addition, Egger’s regression (Table 5) was
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also used to supplement the assessment of publication bias. The results revealed
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the non-significant p-value of all parameters.
7
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Sensitivity analysis
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Due to small sample size (less than 10) and asymmetric distribution in
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funnel plots could be detected visually, the possibility of publication bias could not
11
be excluded. Results from the method of trim and fill is shown in figure 6. The
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adjusted pooled mean values are shown in table 6 as the values in parenthesis. The
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new pooled mean are as follows; Zygomatic width (2.385 mm), PNS (3.337 mm),
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ANS (4.562 mm), Alveolar molar width (4.799 mm) and IPMW (4.992 mm).
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16
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Finally, subgroup analysis could not be performed due to small sample size
of each parameter was less than 3 in this study.
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Risk of bias within studies
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The quality assessment of each study is shown in table 7. All studies
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show low level of quality (4-5 scores), mostly due to the study design which were
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retrospective settings. Five studies showed method of sample size calculation and
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considered as score 1.8,13,16,17 None of the studies had blinding of measurement.
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Only two studies performed comparison of the confounding factors in
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intervention.13,22
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9
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DISCUSSION
Our systematic review and meta-analysis included data from 14 studies,
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which assessed the treatment effect of MARPE in late adolescents and adult
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patients using CBCT evaluation.
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In coronal view, we found progressive skeletal and dental expansion as
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pyramidal pattern (Fig 7). For skeletal change, the greatest expansion was at ANS
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(4.56 mm) followed by PNS (3.34 mm), J-J width (3.12 mm), nasal width (2.68
16
mm) and zygomatic width (2.39 mm) respectively. The amount of AMW change
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was 4.80 mm. Regarding dental change, the greatest expansion was at IMW (5.99
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mm), followed by IPMW (4.99 mm) and the least was ICW (3.96 mm). Overall,
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the results indicated that MARPE could deliver maxillary expansion in late
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adolescents and adult patients with differential amount of skeletal expansion
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alveolar bone bending and dental tipping effects.
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Skeletal expansion
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Our meta-analysis results were generally in agreement with most studies
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which found that the expansion pattern, in coronal perspective, was largest at
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inferior level then gradually decreased superiorly.7,8,15 The greatest skeletal
15
1
expansion was at the palate and less expansion at the anatomy farther away from
2
the MARPE device. This phenomenon could be explained by finite element study
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which showed that the stresses distributed from MARPE demonstrated tension and
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compression directed to the palate.30
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Midpalatal suture separation
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Regarding midpalatal suture separation, majority of studies reported that
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MARPE created the parallel split pattern of midpalatal suture.8,12,13,16,17
9
However, our study showed v shape expansion pattern with more opening in the
10
anterior (ANS) and less opening in the posterior part (PNS) with the posterior-
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anterior ratio of 73.25 % (adjusted value of PNS 3.34 mm/ ANS 4.56 mm). This
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ratio was less than the value reported by Baik et al.8 who reported the value of
13
90% ratio and Cantarella et al.16 who reported the value of 89.6% (PNS 4.3 mm/
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ANS 4.8 mm).
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Although the skeletal and dental effects of MARPE had been reported by
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several studies, to our knowledge, there was only one systematic review study by
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Coloccia et al.31 and 1 meta-analysis paper by Kapetanović et al.1 After
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comparative assessment, we found that our study showed superior strength than
20
these two publications which was attributed to our robust inclusion criteria and
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homogenous study characteristics.
22
23
Comparison of our study with Coloccia et al.31 revealed that only 3 of the
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recruited papers were the same, but 11 papers were different from our study. The
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reason of this dissimilarity was because the average age of several papers in
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Coloccia et al.’s31 included young children (mean age ranged from 9.3 to 22.6
27
years). In addition, they also included both bone-borne and hybrid expander
16
1
supported with either 2 or 4 miniscrews, while our study recruited only the hybrid
2
expander with 4 miniscrews.
3
4
In the meta-analysis study by Kapetanovic et al.1, 5 recruited paper were the
5
same but 4 papers were different from our study. It should be noted that
6
Kapetanovic et al.1 recruited mixed outcomes measured from CBCT image, 2
7
dimension radiographs or dental cast while our study strictly recruited only the
8
CBCT studies. Moreover, the skeletal width increase (2.33 mm) in their study was
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pooled from various anatomical landmarks such as the midpalatal suture, jugular,
10
nasal floor or hard palate while our study separated the levels of these landmarks.
11
Similarly, only one IMW value was reported for dental expansion by Kapetanovic
12
et al.1 while our study included the ICW, IPMW and IMW. Therefore, the validity
13
of values reported in their study could be debatable. In another word, the pattern
14
of skeletal and dental expansion could be better distinguished in our study.
15
16
To our knowledge, there was only 2 retrospective cohort studies by Jesus et
17
al.22 and Oliveira et al.13, who compared the effectiveness between MARPE and
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SARPE in late adolescents and adults. They concluded that MARPE could
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produce better skeletal changes, a parallel palatal expansion with less dentoalveolar
20
changes than SARPE. Our result also showed that MARPE could create skeletal
21
change with the percentage twice greater than dental change. However, our V
22
shape midpalatal suture expansion was not in agreement with the above 2 papers.
23
Due to this conflicting point, more cohort or RCT studies are yet needed to verify
24
the expansion effect of MARPE in comparison with SARPE.
25
26
Dental Effect
27
According to figure 7 and table 6, we found that the pattern of dental
17
1
expansion was dissimilar to the midpalatal suture expansion. The mean dental
2
expansion was greatest at molars then reduced progressively to the canine which
3
was contradicting to PNS-ANS expansion pattern. This phenomenon may imply
4
that there might be greater buccally tipping of upper first molar than premolar and
5
canines respectively. This buccal tipping of molar was observed after MARPE
6
treatment which ranged from 2°-8° degrees 1,17,18 So, clinician should realize that
7
there might still be a chance of some dental tipping in MARPE appliance.
8
9
10
Percentage Expansion
In our study, the percentage of skeletal expansion was 55.76% (PNS),
11
alveolar molar width expansion was 24.37% (AMW) and dental expansion was
12
19.87% (IMW). Our results indicated that MARPE promotes twice the amount of
13
skeletal than dental expansion.
14
Interestingly, the percentage expansion was different among CBCT studies.
15
Our study and Clement et al.’s20 showed that the percentage of midpalatal suture
16
expansion was above 50%, which was greater than the dental expansion. While the
17
other 3 CBCT studies showed greater dental expansion than skeletal
18
expansion.1,15,18 These contradicting results could be attributed to various
19
confounding parameters such as difference of anatomical landmarks, appliance
20
design, appliance position, or cortical engagement of miniscrews etc.
21
22
Indirect comparison with SARPE
23
Most clinicians are interested to know whether MARPE and SARPE with
24
pterygoid dysjunction had comparable effects. So far, there was only one meta-
25
analysis of SARPE published by Bortolotti et al.32 Indirect comparison with our
26
study demonstrated that the skeletal expansion in SARPE (3.3 mm) accounted for
27
almost 50% of the total expansion which was comparable with MARPE value of
18
1
55.76% in our study (3.34 mm at PNS). However, SARPE created greater dental
2
expansion (IMW 7.0 mm) than our MARPE value (IMW 5.99 mm). The limited
3
evidence at present may imply that MARPE could create skeletal effect more than
4
dental effect which could be considered as comparable as SARPE.
5
6
7
Limitations
Due to the fact that the included papers in this study were mostly
8
retrospective one-group pretest-posttest study design with small sample size (less
9
than 25), it failed to attain the high-level quality of evidence which seem to be a
10
crucial point in evidence-based decision-making.
11
12
There might also be residual heterogeneity in some studies 8,16,17 which may
13
slightly affect the results. For example, the mean age of patients in studies of
14
Cantarella et al.,16 Li N et al.,8 and Moon et al.17, which was 17.2, 19.4 and 19.2
15
respectively, may include a few subjects who might be around 15 years old.
16
Regarding the device design, there were 2 studies with the extension arm to the
17
premolars while the rest of studies were not. ICW in our study had small number
18
of studies (only 3 papers). In addition, many outcomes associated with MARPE
19
could not be evaluated due to too small number of studies (less than 3 papers), for
20
example, mono-cortical / bi-cortical miniscrew, asymmetric expansion,
21
pterygomaxillary dysjunction, etc. Thus, it is suggested that these parameters
22
should be included in future study.
23
24
Lastly, clinicians may interpret this conclusion with cautions and should
25
consider the potential benefits of treatment effectiveness against the side effects.
26
Besides, further well-design with more cohort studies or randomized clinical trials
27
should be provided in the future to strengthen the conclusion and determine the
19
1
effectiveness of MARPE.
2
3
4
5
CONCLUSIONS
•
In coronal view, MARPE created skeletal and dental expansion as
pyramidal pattern
6
• The pooled mean effect of skeletal expansion were as follows; ZMW 2.39
7
mm, nasal width 2.68 mm, jugular width 3.12 mm, , PNS 3.34 mm and
8
ANS 4.56 mm
9
10
11
12
• Midpalatal suture split demonstrated v shape pattern with greater expansion
at ANS than PNS.
• Posterior-anterior ratio (PNS/ ANS) of midpalatal suture separation was
73.24 %
13
• The pooled mean effect of alveolar molar width was 4.80 mm
14
• The pooled mean effect of dental expansion were as follows; ICW 3.96
15
16
17
18
19
mm, IPMW 5.22 mm. and IMW 5.99 mm.
• Percentage of expansion showed the effect at skeletal (PNS) 55.76% ,
alveolar molar width 24.37% and dental IMW 19.87%.
• MARPE could expand the constricted maxilla in late adolescents to adult
patients.
20
21
ACKNOWLEDGEMENTS
22
23
Authors would like to acknowledge Faculty of Dentistry, Mahidol University for research
24
funding support.
25
26
27
CONFLICT OF INTERESTS: None
20
1
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26. Moon HW, Kim MJ, Ahn HW, Kim SJ, Kim SH, Chung KR et al. Molar
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27. Nguyen H, Shin JW, Giap H-V, Kim KB, Chae HS, Kim YH et al.
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12
rapid palatal expansion: a systematic review of randomized controlled
13
trials. Eur J Orthod 2019;42:434-40.
14
15
25
1
2
3
4
5
6
Figure 1 PRISMA Flow Diagram
26
1
2
3
Figure 2 Forest plots of skeletal expansion
27
1
2
3
Figure 3 Forest plots of alveolar molar width expansion
28
1
2
3
Figure 4 Forest plots of dental expansion
29
1
2
Figure 5 Funnel plots of skeletal, alveolar width and dental expansion from
meta-analysis
3
4
ICW = inter-canine width;
5
IPMW = inter-premolar width;
6
IMW = inter-molar width
7
8
9
30
1
2
Figure 6 Trim and fill funnel plots of skeletal, alveolar width and dental
expansion from meta-analysis
3
4
ICW = inter-canine width;
5
IPMW = inter-premolar width;
6
IMW = inter-molar width
7
8
9
31
1
2
Figure 7 Summary of adjusted pooled mean estimate of skeletal, alveolar
width and dental expansion
3
4
ZMW = zygomatic width, J-J width = jugular width,
5
AMW = alveolar molar width
6
ICW = inter-canine width; IPMW = inter-premolar width;
7
IMW = inter-molar width
8
9
10
11
32
1
Table 1. Inclusion and exclusion Criteria: PICOS framework
Inclusion Criteria
Exclusion Criteria
Participants (P)
- Adult
- Maxillary transverse deficiency
- Children, Growing
- Systemic disease/ craniofacial
anomalies/ syndrome
Intervention (I)
- Non orthognatic surgery
- 4 micro implant 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 micro implant assisted rapid
maxillary expansion
Comparison (C): compared vs post
treatment or MARPE VS SARPE
2
3
4
5
6
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
33
1
Table 2. Study Characteristics
Author
1.Calil
et al. 2021
2.Cantarella
et al. 2017
3.Clement
et al. 2017
4.Elkenawy
et al. 2020
N
Study Design
Setting
16
Retrospective
cohort
University
Dentistry
institute
15
Retrospective
University
10
31
Prospective
Retrospective
University
University
Race
Compare
Appliance
Appliance
Design
Diameter length
Mean
Age
(SD)
Brazil
Self
ligate
VS
MARPE
PecLab
appliance
(Belo
Horizonte,
Minas Gerais,
Brazil)
Molar without
extension
4 titanium miniimplants
of 1.8 mm diameter
and 8 mm length
No
BioMaterials
Korea
Molar without
extension
ND
No
BioMaterials
Korea
Molar without
extension
USA
No
BioMaterials
Korea
Molar without
extension
PecLab
appliance
(Belo
Horizonte,
Minas Gerais,
Brazil
Molar without
extension
USA
India
5 Jesus
et al. 2021
12
Retrospective
cohort
ND
Brazil
SARPE
with
/without
cinch
6.Li Q
et al. 2020
22
Retrospective
University
China
No
BioMaterials
Korea
Molar without
extension
No
BioMaterials
Korea
Molar without
extension
Molar with
anterior arm
extension
Molar without
extension
7.Li N
et al. 2020
48
Retrospective
University
China
8.Lim
et al. 2017
24
Retrospective
Hospital
Korea
No
Hyrax II;
Dentaurum,
Ispringen,
Germany
9.Moon
et al. 2020
24
Retrospective
University
Korea
Cexpander
BioMaterials
Korea
4 titanium miniimplants
of 1.8 mm diameter
and 11 mm length
4 titanium miniimplants
of 1.5 mm diameter
and 11 mm length
4 titanium miniimplants , ND
4 titanium miniimplants
of 1.5 mm diameter
and 11 mm length
4 titanium miniimplants
of 1.5 mm diameter
and 11 mm length
4 titanium miniimplants diameter,
1.8 mm; length, 7 mm;
Orlus
4 titanium miniimplants
of 1.5 mm diameter
and 11 mm length
Activation
Activation period
success
rate
24.92
(7.6)
2/4-turn a day
until the palatal cusps of
maxillary first molars touch
the buccal cusps of the
mandibular first molars
ND
17.2
(4.2)
2 turns per day,
then 1
activation per
day
until interincisal diastema
appear, then complete
when maxillary width was
equal to mandibular width
100%*
21.5
(ND)
2 turns per day
until the required expansion
was achieved
100%*
20.4
(3.2)
2 turns per day,
then 1
activation per
day
until interincisal diastema
appear, then complete
when maxillary width was
equal to mandibular width
ND
Range
15-39
2 turns a day
for 14 to 18 days,
until full correction
ND
22.6
(4.5)
2 turns every
other day
maxillary skeletal width
was no longer less than
mandible (mean 38 days)
100%*
19.4
(3.3)
one-sixth of
turn
(0.13mm) each
day
maxillary skeletal width
was
no longer less than
mandible
ND
21.6
(3.1)
Once a day
(0.2mm)
until the required expansion
was achieved ( 5 week)
86.84%
19.2
(5.9)
Once a day
(0.2mm)
until the required expansion
was achieved ( 5 week)
ND
34
Author
N
Study Design
Setting
Race
10.Ngan
et al. 2018
8
Retrospective
University
USA
11.Nguyen
et al. 2021
20
Retrospective
University
Korea
Compare
Appliance
Appliance
Design
Diameter length
Mean
Age
(SD)
Activation
No
BioMaterials
Korea
Molar without
extension
4 titanium miniimplants
of 1.8 mm diameter
and 11 mm length
21.9
(1.5)
varied with the
severity of
transverse
discrepancy
No
BioMaterials
Korea
MSE type II
Molar without
extension
4 titanium miniimplants
of 1.8 mm diameter
and 11 mm length
22.4
(17.627.1)
2 turns per day
(0.13mm/turn)
Molar without
extension
12.Oliveira
et al. 2021
17/
15
Retrospective
cohort
University
Brazil
MARPE
VS.
SARPE
PecLab
appliance
(Belo
Horizonte,
Minas Gerais,
Brazil)9 mm
expander
13.Park
et al. 2017
14
Retrospective
University
Korea
No
Hyrax II;
Dentaurum,
Ispringen,
Germany
Molar with
anterior arm
extension
14.Tang
et al. 2021
31
Retrospective
University
China
No
BioMaterials
Korea
Molar without
extension
4 miniscrew unknown
diameter and length
diameter, 1.8 mm;
length, 7 mm;
Orlus,
4 titanium miniimplants
of 1.5 mm diameter
and 11 mm length
\
MAR
PE26
(11)
SARP
E
28.5
(10.5)
Activation period
until 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
overexpansion
until diastema appeared,
after which the rate was
reduced to one turn per day,
stop when required amount
was achieved
20% overexpansion
100%*
100%*
2/4
immediately
after mini
implant
placement and
2/4 turns daily
(14-18)
until full correction
86.96%
20.1
(2.4)
Once a day
(0.2mm)
until the required expansion
was achieved
84.21%
22.14
(4.76)
Once a day
(0.13mm)
ranging from 40 to 60 turns
1
Success rate = the percentage of patients who exhibited success of maxillary expansion to required amount.100%* = Author mentioned successful
2
midpalatal suture split, however there was no numerical percentage reported.
3
success
rate
92%
35
1
Table 3. Outcomes classified by skeletal, alveolar width and dental expansion
Author
2
3
4
5
6
N
Mean
S.D.
Combined
measurements
1 Elkenawy et al. 2020
31
3.99
1.60
22
0.50
1.00
Zygomatic 2 Li Q et al. 2020
3 Li N et al. 2020
48
1.77
0.90
width
4 Tang et al. 2021
31
1.45
1.04
1 Calil et al. 2021
16
2.82
1.54
2 Jesus et al. 2021
12
3.46
1.95
3 Li Q et al. 2020
22
2.30
1.20
4 Li N et al. 2020
48
3.58
1.39
Nasal
5 Lim et al. 2017
24
2.20
1.01
width
6 Moon et al. 2020
24
2.45
1.37
7 Ngan et al. 2018
8
2.53
0.53
8 Oliveira et al. 2021
17
2.91
1.62
9 Tang et al. 2021
31
2.33
1.22
1 Calil et al. 2021
16
3.06
1.81
2 Jesus et al. 2021
12
3.20
1.92
3 Li Q et al. 2020
22
2.00
1.00
J-J width
4 Li N et al. 2020
48
4.69
1.31
5 Tang et al. 2021
31
2.65
0.98
1 Cantarella et al. 2017
15
4.33
1.74
31
4.77
2.65
Midpalatal 2 Elkenawy et al. 2020
3 Ngan et al. 2018
8
3.27
0.46
suture
4 Nguyen et al. 2021
20
3.95
0.50
(PNS)
5 Oliveira et al. 2021
17
2.75
0.85
1 Cantarella et al. 2017
15
4.75
2.59
31
4.98
1.94
Midpalatal 2 Elkenawy et al. 2020
3 Ngan et al. 2018
8
3.53
0.80
suture
4 Nguyen et al. 2021
20
4.83
0.53
(ANS)
5 Oliveira et al. 2021
17
3.69
1.42
N = sample size
J-J width = Jugular width*Combined Mean and S.D. from multiple groups using
https://www.statstodo.com/CombineMeansSDs.php
3 groups*
ant./ post*
3 groups*
ant./ post*
3 groups*
36
1
Table 4. Outcomes of alveolar molar width and dental expansion
7
N
10
24
20
17
16
10
24
32
20
48
17
14
16
10
12
48
24
24
8
17
14
Mean
6.50
2.60
4.19
3.86
3.04
5.83
3.02
3.63
5.50
5.87
5.21
5.50
6.37
7.33
5.82
6.95
5.63
4.91
6.26
5.25
5.40
S.D.
1.51
0.85
0.67
1.20
2.03
1.32
1.25
2.14
1.52
1.26
2.25
1.40
1.72
1.96
2.03
1.25
1.90
1.50
1.31
2.34
1.70
1
2
3
4
1
2
ICW
3
1
1st / 2nd PM *
2
1st / 2nd PM *
3
1st / 2nd PM *
IPMW
4
5
1
2
3
4
3 groups *
5
IMW
6
7
8
9
N = sample size
ICW = inter-canine width ; IPMW = inter-premolar width ; IMW = inter-molar width
*Combined Mean and S.D. from multiple groups using
https://www.statstodo.com/CombineMeansSDs.php
Alveolar
molar
width
2
3
4
5
6
Author
Clement et al. 2017
Lim et al. 2017
Nguyen et al. 2021
Oliveira et al. 2021
Calil et al. 2021
Clement et al. 2017
Lim et al. 2017
Calil et al. 2021
Clement et al. 2017
Lim et al. 2017
Oliveira et al. 2021
Park et al. 2017
Calil et al. 2021
Clement et al. 2017
Jesus et al. 2021
Li N et al. 2020
Lim et al. 2017
Moon et al. 2020
Ngan et al. 2018
Oliveira et al. 2021
Park et al. 2017
Combined
measurements
37
1
Table 5. Assessment of heterogeneity and publication bias (Egger’s test) for
2
skeletal, alveolar width and dental expansion
Zygomatic width
Nasal width
Skeletal
J-J width
expansion
PNS
ANS
4/132
9/202
5/129
5/91
5/91
Heterogeneity test
Egger's regression intercept
pp-value
Q-value
I²
Intercept
SE
value
(2-tailed)
97.241
0.000 96.915
5.929
11.815
0.666
33.382
0.000 76.035
0.872
2.569
0.744
103.526
0.000 96.136 -0.689
6.924
0.927
39.477
0.000 89.868
0.337
3.467
0.929
26.285
0.000 84.782 -2.116
2.192
0.406
Alveolar Alveolar
expansion Molar width
4/71
85.575
0.000
96.494
6.114
7.562
0.504
ICW
Dental
IPMW
expansion
IMW
3/50
5/131
9/173
34.807
14.460
46.970
0.000 94.254
0.000 72.337
0.000 82.968
5.539
-4.236
-2.526
10.361
2.207
1.880
0.344
0.151
0.221
Group
3
4
5
6
7
8
Parameter
n/N
J-J width = Jugular width
ICW = inter-canine width ; IPMW = inter-premolar width ; IMW = inter-molar width
38
1
Table 6. The results of pooled mean estimate for skeletal, alveolar width and dental
2
expansion from meta-analysis including adjusted values after the method of trim
3
and fill
Parameter
n
N
Mean
SE
95% CI
Zygomatic width
4
132
0.548
9
5
5
202
129
91
5
91
1.910
(2.385)**
2.675
3.120
3.715
(3.337)**
4.335
(4.562)**
0.835, 2.985
(1.120, 3.649)**
2.325, 3.026
1.990, 4.250
3.121, 4.310
(2.754, 3.919)**
3.674, 4.997
(3.938, 5.187)**
4
71
Nasal width
Skeletal
J-J width
expansion
PNS
ANS
Alveolar
Alveolar
Molar width
expansion
ICW
Dental
IPMW
expansion
IMW
4.221
0.179
0.576
0.303
0.338
0.608
(4.799)**
3.030, 5.412
(3.112, 6.486)**
3
50
3.959
0.926
2.144, 5.774
5
131
5.218
0.355
4.522, 5.914
(4.992)**
9
173
5.985
(4.229, 5.755)**
0.318
5.361, 6.609
4
5
6
7
8
9
10
n = number of articles; N = number of subjects
Values in parenthesis ** = adjusted values after the method of trim and fill
ICW = inter-canine width ; IPMW = inter-premolar width ; IMW = inter-molar width
39
1
Table 7. Assessment of risk of bias within studies
2
Study
Study
design
Calil et al. 2021
Cantarella et al. 2017
Clement et al. 2017
Elkenawy et al. 2020
Jesus et al. 2021
Li Q et al. 2020
Li N et al. 2020 (17)
lim et al. 2017
moon et al. 2020
Ngan et al. 2018
Nguyen et al. 2021
Oliveira et al. 2021
Park et al. 2017
Tang et al. 2021
Overall estimate
0
0
1
0
0
0
0
0
0
0
0
0
0
0
Sampl
e
size
1
1
0
1
0
1
1
0
0
0
0
0
0
0
Selection
descriptio
n
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Valid
measuremen
t
method
1
1
1
1
1
1
1
1
1
1
1
1
1
1
Method
error
analysis
Blindin
g
Statistics
Confou
nding
factors
1
1
0
1
1
1
1
1
1
1
1
1
1
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
0
0
0
0
1
0
0
0
0
0
0
1
0
0
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Study Design: RCT = 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 2006
Tota
l
scor
e
5
5
4
5
5
5
5
4
4
4
4
5
4
4
4.5
Judged
quality
standar
d
low
low
low
low
low
low
low
low
low
low
low
low
low
low
low
40
1
Table Appendix 1: Search strategy used classified by source of electronic database
Database
Search strategy
Pubmed
Search: (((micro implant assisted rapid palatal expan*[Title/Abstract] OR
micro implant assisted palatal expan*[Title/Abstract] OR micro implant
assisted rapid maxillary expan*[Title/Abstract] OR micro implant assisted
maxillary expan*[Title/Abstract] OR mini implant assisted rapid palatal
expan*[Title/Abstract] OR mini implant assisted palatal expan*[Title/Abstract]
OR mini implant assisted rapid maxillary expan*[Title/Abstract] OR mini
implant assisted maxillary expan*[Title/Abstract] OR mini implant maxillary
expan*[Title/Abstract] OR miniscrew assisted rapid palatal
expan*[Title/Abstract] OR miniscrew assisted palatal expan*[Title/Abstract]
OR miniscrew assisted rapid maxillary expan*[Title/Abstract] OR miniscrew
assisted maxillary expan*[Title/Abstract] OR microscrew assisted rapid palatal
expan*[Title/Abstract] OR microscrew assisted palatal expan*[Title/Abstract]
OR microscrew assisted rapid maxillary expan*[Title/Abstract] OR microscrew
assisted maxillary expan*[Title/Abstract] OR Bone anchored rapid palatal
expan*[Title/Abstract] OR Bone anchored rapid maxillary
expan*[Title/Abstract] OR Bone-anchored hybrid Hyrax
expan*[Title/Abstract] OR hybrid rapid maxillary expan*[Title/Abstract] OR
miniscrew supported hybrid hyrax[Title/Abstract] OR Hybrid Hyrax
expan*[Title/Abstract] OR maxillary skeletal expan*[Title/Abstract] OR Tooth
bone borne rapid maxillary expan*[Title/Abstract] OR Tooth[Title/Abstract]
AND bone borne expan*[Title/Abstract] OR Tooth bone borne
RME[Title/Abstract] OR Tooth bone borne RPE[Title/Abstract] OR Surgically
assisted rapid palatal expan*[Title/Abstract] OR SARPE[Title/Abstract] OR
surgically assisted rapid maxillary expan*[Title/Abstract] OR
SARME[Title/Abstract] OR Surgically Assisted Rapid Palatomaxillary
Expan*[Title/Abstract] OR MARPE[Title/Abstract] OR MSE[Title/Abstract]
OR MARME[Title/Abstract]) AND (CBCT[Title/Abstract] OR Cone Beam
CT[Title/Abstract] OR Cone beam computed tomography[Title/Abstract]))
AND (Expansion[Title/Abstract])) AND (Maxilla[Title/Abstract] OR
Maxillary[Title/Abstract])
Embase
(('micro implant assisted rapid palatal expan*':ab,ti OR 'micro implant assisted
palatal expan*':ab,ti OR 'micro implant assisted rapid maxillary expan*':ab,ti
OR 'micro implant assisted maxillary expan*':ab,ti OR 'mini implant assisted
rapid palatal expan*':ab,ti OR 'mini implant assisted palatal expan*':ab,ti OR
'mini implant assisted rapid maxillary expan*':ab,ti OR 'mini implant assisted
maxillary expan*':ab,ti OR 'mini implant maxillary expan*':ab,ti OR
'miniscrew assisted rapid palatal expan*':ab,ti OR 'miniscrew assisted palatal
expan*':ab,ti OR 'miniscrew assisted rapid maxillary expan*':ab,ti OR
'miniscrew assisted maxillary expan*':ab,ti OR 'microscrew assisted rapid
palatal expan*':ab,ti OR 'microscrew assisted palatal expan*':ab,ti OR
'microscrew assisted rapid maxillary expan*':ab,ti OR 'microscrew assisted
maxillary expan*':ab,ti OR 'bone anchored rapid palatal expan*':ab,ti OR 'bone
anchored rapid maxillary expan*':ab,ti OR 'bone anchored hybrid hyrax
expan*':ab,ti OR 'hybrid rapid maxillary expan*':ab,ti OR 'miniscrew supported
hybrid hyrax':ab,ti OR 'hybrid hyrax expan*':ab,ti OR 'maxillary skeletal
expan*':ab,ti OR 'tooth bone borne rapid maxillary expan*':ab,ti OR tooth:ab,ti)
AND 'bone borne expan*':ab,ti OR 'tooth bone borne rme':ab,ti OR 'tooth bone
borne rpe':ab,ti OR 'surgically assisted rapid palatal expan*':ab,ti OR sarpe:ab,ti
41
Database
Search strategy
OR 'surgically assisted rapid maxillary expan*':ab,ti OR sarme:ab,ti OR
'surgically assisted rapid palatomaxillary expan*':ab,ti OR marpe:ab,ti OR
mse:ab,ti OR marme:ab,ti) AND (cbct:ab,ti OR 'cone beam ct':ab,ti OR 'cone
beam computed tomography':ab,ti) AND expansion:ab,ti AND (maxilla:ab,ti
OR maxillary:ab,ti)
Scopus
(TITLE-ABS-KEY("micro implant assisted rapid palatal expan*" OR "micro
implant assisted palatal expan*" OR "micro implant assisted rapid maxillary
expan*" OR "micro implant assisted maxillary expan*" OR "mini implant
assisted rapid palatal expan*" OR "mini implant assisted palatal expan*" OR
"mini implant assisted rapid maxillary expan*" OR "mini implant assisted
maxillary expan*" OR "mini implant maxillary expan*" OR "miniscrew
assisted rapid palatal expan*" OR "miniscrew assisted palatal expan*" OR
"miniscrew assisted rapid maxillary expan*" OR "miniscrew assisted maxillary
expan*" OR "microscrew assisted rapid palatal expan*" OR "microscrew
assisted palatal expan*" OR "microscrew assisted rapid maxillary expan*" OR
"microscrew assisted maxillary expan*" OR "Bone anchored rapid palatal
expan*" OR "Bone anchored rapid maxillary expan*" OR "Bone anchored
hybrid Hyrax expan*" OR "hybrid rapid maxillary expan*" OR "miniscrew
supported hybrid hyrax" OR "Hybrid Hyrax expan*" OR "maxillary skeletal
expan*" OR "Tooth bone borne rapid maxillary expan*" OR "Tooth and bone
borne expan*" OR "Tooth bone borne RME" OR "Tooth bone borne RPE" OR
"Surgically assisted rapid palatal expan*" OR SARPE OR "surgically assisted
rapid maxillary expan*" OR SARME OR "Surgically Assisted Rapid
Palatomaxillary Expan*" OR MARPE OR MSE OR MARME) AND TITLEABS-KEY(CBCT OR "Cone Beam CT" OR "Cone beam computed
tomography") AND TITLE-ABS-KEY(Expansion) AND TITLE-ABSKEY(Maxilla OR Maxillary))
Web of Science
ALL FIELDS: ("micro implant assisted rapid palatal expan*" OR "micro
implant assisted palatal expan*" OR "micro implant assisted rapid maxillary
expan*" OR "micro implant assisted maxillary expan*" OR "mini implant
assisted rapid palatal expan*" OR "mini implant assisted palatal expan*" OR
"mini implant assisted rapid maxillary expan*" OR "mini implant assisted
maxillary expan*" OR "mini implant maxillary expan*" OR "miniscrew
assisted rapid palatal expan*" OR "miniscrew assisted palatal expan*" OR
"miniscrew assisted rapid maxillary expan*" OR "miniscrew assisted maxillary
expan*" OR "microscrew assisted rapid palatal expan*" OR "microscrew
assisted palatal expan*" OR "microscrew assisted rapid maxillary expan*" OR
"microscrew assisted maxillary expan*" OR "Bone anchored rapid palatal
expan*" OR "Bone anchored rapid maxillary expan*" OR "Bone anchored
hybrid Hyrax expan*" OR "hybrid rapid maxillary expan*" OR "miniscrew
supported hybrid hyrax" OR "Hybrid Hyrax expan*" OR "maxillary skeletal
expan*" OR "Tooth bone borne rapid maxillary expan*" OR "Tooth and bone
borne expan*" OR "Tooth bone borne RME" OR "Tooth bone borne RPE" OR
"Surgically assisted rapid palatal expan*" OR SARPE OR "surgically assisted
rapid maxillary expan*" OR SARME OR "Surgically Assisted Rapid
Palatomaxillary Expan*" OR MARPE OR MSE OR MARME) AND ALL
FIELDS: (CBCT OR "Cone Beam CT" OR "Cone beam computed
tomography") AND ALL FIELDS: (Expansion) AND ALL FIELDS: (Maxilla
OR Maxillary
42
1
2
View publication stats
Database
Search strategy
Cochrane Library
"micro implant assisted rapid palatal expan*" OR "micro implant assisted
palatal expan*" OR "micro implant assisted rapid maxillary expan*" OR
"micro implant assisted maxillary expan*" OR "mini implant assisted rapid
palatal expan*" OR "mini implant assisted palatal expan*" OR "mini implant
assisted rapid maxillary expan*" OR "mini implant assisted maxillary expan*"
OR "mini implant maxillary expan*" OR "miniscrew assisted rapid palatal
expan*" OR "miniscrew assisted palatal expan*" OR "miniscrew assisted rapid
maxillary expan*" OR "miniscrew assisted maxillary expan*" OR "microscrew
assisted rapid palatal expan*" OR "microscrew assisted palatal expan*" OR
"microscrew assisted rapid maxillary expan*" OR "microscrew assisted
maxillary expan*" OR "Bone anchored rapid palatal expan*" OR "Bone
anchored rapid maxillary expan*" OR "Bone anchored hybrid Hyrax expan*"
OR "hybrid rapid maxillary expan*" OR "miniscrew supported hybrid hyrax"
OR "Hybrid Hyrax expan*" OR "maxillary skeletal expan*" OR "Tooth bone
borne rapid maxillary expan*" OR "Tooth and bone borne expan*" OR "Tooth
bone borne RME" OR "Tooth bone borne RPE" OR "Surgically assisted rapid
palatal expan*" OR SARPE OR "surgically assisted rapid maxillary expan*"
OR SARME OR "Surgically Assisted Rapid Palatomaxillary Expan*" OR
MARPE OR MSE OR MARME in Title Abstract Keyword AND CBCT OR
"Cone Beam CT" OR "Cone beam computed tomography" in Title Abstract
Keyword AND Expansion in Title Abstract Keyword AND Maxilla OR
Maxillary in Title Abstract Keyword - (Word variations have been searched)