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Article

Factors Affecting MARPE Success in Adults: Analysis of Age, Sex, Maxillary Width, and Midpalatal Suture Bone Density

by
Echarri-Nicolás Javier
1,
González-Olmo María José
2,*,
Echarri-Labiondo Pablo
1,
Olmos-Valverde Marta
2 and
Romero Martín
2
1
Athenea Dental Institute, San Jorge University, 50830 Zaragoza, Spain
2
Department of Orthodontics, Rey Juan Carlos University, 28922 Alcorcón, Spain
*
Author to whom correspondence should be addressed.
Appl. Sci. 2024, 14(22), 10590; https://doi.org/10.3390/app142210590
Submission received: 24 September 2024 / Revised: 3 November 2024 / Accepted: 15 November 2024 / Published: 17 November 2024
(This article belongs to the Special Issue Advances in Orthodontic Diagnosis and Treatment: Methods and Applications)
Browse Figure
Versions Notes

Abstract

:
Microimplant-assisted rapid palatal expansion (MARPE) is a technique widely used to treat transverse discrepancies in adult patients. The present study aims to examine how age, sex, maxillary width, and suture bone density might influence MARPE efficacy. It also analyzes bone density variations across the midpalatal suture regions. Materials and Methods: This retrospective study included 30 adult patients who underwent MARPE treatment. Pre- and post-treatment CT scans were analyzed to quantify the maxillary width and bone density measured in Hounsfield units (HUs) in the anterior, middle, and posterior nasal spine regions. Statistical analyses were carried out and included descriptive statistics, t-tests, and effect size calculations. Results: Younger patients (age 22.13 ± 4.58) had significantly higher success rates compared to older patients (aged 25.66 ± 4.67). No significant differences were found regarding sex or the initial maxillary width. Lower bone density in the middle and posterior nasal spine regions was correlated with higher success rates. Data showed that the anterior nasal spine exhibited higher bone density, but this finding did not affect treatment outcomes significantly. Conclusions: Age seems to be a crucial factor in MARPE success, with younger patients showing better outcomes. Regarding bone density, results showed that its values in the middle and posterior nasal spine regions could be a determinant of treatment success. On the contrary, sex and the initial maxillary width did not appear to affect outcomes. These findings emphasize the importance of preoperative assessments and the consideration of individual anatomical variations for optimal MARPE treatment planning.

1. Introduction

The microimplant-assisted rapid palatal expansion (MARPE) treatment has been extensively described in the literature and noted for its ability to reduce excessive load on the buccal periodontal ligament of the teeth used as anchorage [1]. MARPE devices combine both bone and dental elements, achieving retention through four bicortical microscrews that penetrate the palatal cortical bone and extend to the nasal floor [2]. This technique is particularly effective for adult patients in which the ossification of the midpalatal suture hinders the separation of the maxillary halves when conventional expanders are the elective technique [3,4].
To ensure the correct placement of the expansion device and the bicorticality of microimplants, it is essential to conduct a thorough case study that must include a CBCT (Cone Beam Computed Tomography) scan of the patient [4]. Haga clic o pulse aquí para escribir texto. CBCT can be used to quantitatively evaluate the dental [5], skeletal [6], and upper airway [7] impacts of MARPE treatment. Additionally, it enables the generation of volumetric images, providing a detailed assessment of the anatomy without the overlap of adjacent structures [4]. Some of the disadvantages of CBCT include increased scattered radiation, the limited dynamic range of the X-ray area detectors, artefacts, and the lack of accuracy regarding Hounsfield units (HUs), compared with medical computed tomography (CT) [8]. HUs are defined as linear transformations of the X-ray attenuation coefficients measured from a material, referenced against water [9]. According to the scientific literature, it is feasible to use HUs based on the grey scale values shown in conventional computed tomography (CT), correlating them with bone density [10]; thus, a relationship has been established between the HU values calculated in conventional CT and the grey scale that can be studied in CBCT [8]. Because of all these characteristics and also due to its lower radiation dose compared to conventional CT, CBCT is nowadays considered the standard procedure to measure bone density in dental implantology [11].
The outcome of MARPE is closely linked to the patient’s age, with older patients facing lower success rates. Research indicates that younger individuals, particularly those between the ages of 15 and 19, experience a success rate of approximately 83.3%, whereas for those between 30 and 37, the rate decreases significantly to 20% [12]. Those results are consistent with other research studies [13,14]. This reduction is believed to be related to the increasing ossification and rigidity of the midpalatal suture as individuals age, which makes the suture less responsive to expansion forces. Additionally, other factors like the thickness and density of the posterior palatal bone could also contribute to success, with less ossified regions showing better outcomes [14,15].
Sex, on the other hand, does not significantly appear to influence MARPE results. Studies have found no major differences in the success rates between males and females, suggesting that sex-specific anatomical variations do not substantially affect the procedure’s efficacy [10,11].
Thus, the maturation stage of the suture and the precise placement of mini-implants remain critical factors that can affect the outcome, highlighting the importance of thorough preoperative evaluation.
As a result of all the above, the present investigation aims to examine whether the efficacy of midpalatal suture expansion, achieved through microimplant-assisted rapid palatal expansion (MARPE), is significantly influenced by variables such as age, sex, the maxillary width, or the suture bone density. Furthermore, this study seeks to analyze potential variations in bone density across the anterior, middle, and posterior regions of the midpalatal suture, and to evaluate the impact of these density disparities on the success or failure of the expansion process.

2. Materials and Methods

2.1. Design and Participants

Data utilized in this study were collected retrospectively. The sample consisted of patients who had undergone treatment with MARPE (Figure 1) at a private dental clinic (xxxx) between September 2021 and March 2023.
The inclusion criteria focused on adult individuals with maxillary constriction who were refused traditional surgical intervention and had opted for maxillary expansion with the aid of microimplants. Exclusion criteria included the presence of craniofacial anomalies or a cleft palate, refusal to pursue an orthodontic treatment, or refusal to participate or to provide informed consent.
Anonymized demographic data and sample images were employed in the analysis. Calculations to determine the sample size were based on the results of a pilot study that included ten patients. The mean and standard deviation (SD) obtained for the change in the maxillary width were 2.66 ± 0.35 mm in the group where the suture was opened, and 2.66 ± 0.36 mm in the group where the suture opening was unsuccessful. Using a two-tailed test with a significance level of alpha 0.05 and a beta risk of 0.2 for the bilateral contrast, it was calculated that 14 participants per group were required. Therefore, 30 subjects were selected to provide an additional margin. The study sample consisted of patients aged between 18 and 34 years (mean of 23.9 ± 4.88 years), with a sex distribution of 53.3% male and 46.7% female, and an initial mean maxillary width of 55.45 ± 4.70 mm. The maxillary suture bone density, measured in Hounsfield units (HUs), showed mean values of 970.83 ± 234.74 HUs at the anterior nasal spine, 743.63 ± 297.44 HUs at the middle nasal spine, and 810.47 ± 224.49 HUs at the posterior nasal spine.

2.2. Procedure and Measurements

Microimplants of the Palalign Round Head Type (produced by Osteonic Co., Ltd., Seoul, Republic of Korea), composed of a Ti6Al4V alloy, were utilized, with a 1.8 mm diameter and lengths of 10, 12, 14, or 16 mm, depending on the clinical case-specific needs. The importance of bicortical placement was emphasized to enhance stability and reduce the risk of microimplant deformation or fracture.
Regarding the appliance, molar bands were applied to the first upper molars with anterior bonded arms on the palatal surfaces of the first and second premolars; the expansion screw used was the Power MARPE Type 1 model (also from Osteonic Co., Ltd., Seoul, Republic of Korea), which was initially activated at four turns per day until the appearance of an interincisal diastema; the activation rate was then reduced to two turns per day until an overcorrection of 1.5 mm per side was achieved. All orthodontic treatments were performed by the same orthodontist. Patients received detailed explanations about the procedure and provided informed consent to participate in the study. The study protocol received approval from the Rey Juan Carlos University Ethics Committee under the internal reference number (1504202110721).
A CBCT radiographic scan was performed on each patient using a NewTom Giano HR scanner (QR, Verona, Italy) with a voxel size of 300 μm and a field of view (FOV) of 16 × 18 cm. Imaging was conducted both before and after the application of MARPE treatment, enabling the calculation of various parameters from the 3D X-ray images obtained at two specific time points, designated as T0 (pre-treatment) and T1 (post-treatment) (see Table 1), and all measurements were carried out by the same operator.
The morphology of the midpalatal suture opening was assessed by measuring different parameters such as the aperture at the levels of the incisive foramen, the junction of the midpalatal suture and the transverse palatal suture, and the posterior nasal spine. The HUs were measured using NNT software (QR, Verona, Italy). The HU measurements were taken by positioning the axial plane, from the sagittal view, at the three measurement points: ANS, MNS, and PNS. The recorded HU values were those provided by the NNT software. A parallel suture opening was defined as when the aperture measurements at the three anatomical points were equal. If the aperture at the incisive foramen was greater, the opening was classified as anterior; if the measurement was greater at the posterior nasal spine, the opening was considered posterior. The average interval between these two measurements was 1.5 months.

2.3. Statistical Analysis

All statistical analyses were performed using SPSS version 28.0 for Windows (IBM, Armonk, NY, USA). The data analysis included the Shapiro–Wilk test to evaluate the assumption of normality, which was confirmed. A descriptive analysis was conducted to present sample characteristics, including age, sex, and the maxillary width at T0 and T1, bone density, and the suture opening achieved post-treatment. The intraclass correlation coefficient (ICC) was calculated, considering ICC <0.4 as low, between 0.4 and 0.75 as acceptable, and >0.75 as high. Each indicator was measured three times at each investigation time, and measurement errors were determined.
Subsequently, a paired samples t-test was performed to compare bone density in different parts of the maxilla, as well as the analysis of mean differences for midpalatal suture success with a t-test, for which the effect size was calculated using Cohen’s d. Effect sizes (ESs) were considered to be low at d ≈ 0.2, medium at ≈ 0.5, and high at ≈ 0.8 [12], and a Chi-square test was performed. Significance levels were set at 0.05.

3. Results

3.1. Method Errors

This study shows high reliability in the assessments carried out, with an intraclass correlation coefficient (ICC) above 0.9 (see Table 2).

3.2. Descriptive Analyses

Table 3 presents the descriptive data of the measured variables. An increase in the maxillary width of 2.61 mm (±1.93 mm) was observed from T0 and T1. In 50% of the cases, the midpalatal suture was opened in parallel.

3.3. Differences in Bone Density (ANS, MNS, and PNS)

Regarding bone density (Table 4), higher values were found in the anterior (970.83 ± 234.74) and posterior (810.47 ± 224.49) nasal spine, while the middle nasal spine showed lower values (743.63 ± 297.44). Significant differences in bone density were detected between ANS and MNS (t = 4.689, p < 0.001) and between ANS and PNS (t = 3.850, p < 0.001).

3.4. Success in the Opening of the Midpalatal Suture

The comparative analysis between the success and failure groups for midpalatal suture opening, presented in Table 5, reveals statistically significant differences in several parameters, such as a significantly lower chronological age, a higher value of the MxWT1 (post-treatment maxillary width), and reduced bone density in the MNS (middle nasal spine) and PNS (posterior nasal spine) regions in the success group.
Importantly, no statistically significant differences were observed between groups related to sex (success: 46.7% males, 53.3% females; failure: 60% males, 40% females; X2 = 0.536, p = 0.467), the MxWT0, the MxWT0T1, or bone density in the ANS region.
These findings suggest a correlation between certain anatomical and age factors and the success of midpalatal suture opening.

4. Discussion

MARPE is a technique that has gained popularity for treating transverse discrepancies in adult patients where the midpalatal suture is already fused or presents significant resistance to conventional expansion [13]. One of the determining factors for the success of this treatment is the likelihood that the midpalatal suture will open adequately under the forces exerted by the MARPE device. In this context, studying the anatomy and bone density of the midpalatal suture is of vital importance in predicting the success or failure of the treatment [14].
This research aims to shed light on the success of midpalatal suture opening and its relationship to the variables of age, sex, and bone density calculated with CBCT UHs.
The midpalatal suture is a key anatomical structure for maxillary expansion treatments. During development, this suture undergoes a process of synostosis or fusion, which varies with age and between individuals. In adolescents, the suture is not yet fully fused, which facilitates expansion with conventional appliances [13]. However, in adults, bone strength increases due to progressive ossification, which limits the effectiveness of traditional rapid jaw expansion treatments. The use of microimplants in MARPE helps to transfer expansion forces directly to the basal bone, increasing the likelihood of success, although the structure and density of the midpalatal suture remain important factors [15].
This present study indicates that younger patients, as well as those with lower HU values in the middle and posterior nasal spine (MNS and PNS), are more likely to achieve successful midpalatal suture (MPS) opening.
Studies have shown that the anatomy of the midpalatal suture is highly variable, both in shape and the degree of ossification [16]. The morphology of this suture may influence the resistance to movement of the maxillary segments during expansion. Our findings regarding age are consistent with those found by Handelman [17], who argues that the midpalatal suture in adult patients has greater structural complexity, with areas of partial fusion and greater bone density compared to younger patients, making expansion more difficult and causing a higher risk of complications such as asymmetry in the suture opening.
Additionally, no significant predictive factors for treatment success were identified based on patient sex. These findings align with the existing literature, which also reports no correlation between sex and the success of midpalatal suture opening in microimplant-assisted expansion treatments [14,18,19]. This lack of an association may be attributed to the substantial variability in suture consolidation between individuals.
Different methods have been described to understand the individuality of the maturation status of the midpalatal suture: the obliteration index is not a valid factor to determine the type of expansion treatment in adults [15,20]; midpalatal suture density (MPSD) is the method that has the potential to be used to clinically assess the skeletal response to RPE [21,22], although other research does not recommend grey scale CBCT for the study of midpalatal suture bone density [23].
A key study in this field is that of Angelieri et al. [15], which classified the midpalatal suture into different stages of ossification, using CBCT images to assess the likelihood of suture opening during maxillary expansion. Their classification ranges from stage A (no ossification evident) to stage D (complete ossification), with stage C being the point where suture opening is least predictable. This study highlights the importance of prior CBCT evaluation to determine the degree of ossification of the suture before deciding on the MARPE treatment protocol.
Several studies have addressed the influence of bone density and midpalatal suture anatomy on the success of microimplant-assisted maxillary expansion. Brunetto et al. [24] studied the relationship between cortical bone density and suture opening success in adults treated with MARPE. They found that patients with lower bone density, as assessed by CBCT, had a higher probability of successful expansion compared to those with denser bone. This finding is consistent with previous studies suggesting that bone strength in the midpalatal suture region is a critical factor that should be considered before initiating treatment. The study by Silva et al. [18] compares the skeletal and alveolar effects between hybrid and conventional expanders in growing patients, indicating that the use of microimplant anchorage reduces the negative impact on the bone morphology of posterior teeth but has not been investigated in the adult population.
Oliveira et al. [14] also highlight bone strength as a key factor, suggesting that the degree of ossification and the morphology of the midpalatal suture may predict treatment success. This finding is reinforced in both studies by the use of CBCT imaging to assess suture morphology before expansion. In the systematic review by Liu et al. [25], they concluded that there is evidence of midpalatal suture opening after rapid maxillary expansion and long-term skeletal stability.
One of the main limitations of this study is the lack of consensus in the scientific literature on the reliability of HU measurement using CBCT. Although CBCT has been used in numerous studies, the accuracy and consistency of HU measurements remain a matter of debate among experts, which may affect the interpretation of results [9,23]. Furthermore, the study was limited by the small sample size, which may restrict the generalisability of the findings to a larger population. Finally, another limiting factor is the lack of a long-term follow-up, which prevents the assessment of the effects and outcomes of interventions or treatments over a prolonged period.
The results of this study have a number of important implications for the current practice of orthodontics. One the one hand, the age of the patients plays an important role in the success rate of the MARPE treatment. On the other hand, it was demonstrated that a lower density of the MNS and PNS have a direct impact on the MARPE treatment success. These values can be studied in the CBCT.

5. Conclusions

The study findings indicate that younger patients exhibited significantly higher success rates in MARPE treatment, suggesting age as a crucial factor in palatal expansion efficacy.
Neither sex nor the maxillary width (T0, T1, T0–T1) appeared to influence MARPE treatment success, as no statistically significant differences were observed.
Although the anterior nasal spine (ANS) demonstrated higher bone density compared to the middle and posterior regions, it did not show a significant correlation with treatment success, indicating its potentially minimal impact on MARPE outcomes. Conversely, lower bone density in the middle and posterior nasal spine regions (MNS and PNS) was strongly associated with successful suture opening, highlighting the importance of bone characteristics in treatment results.

Author Contributions

Conceptualization, E.-N.J.; methodology, E.-N.J., E.-L.P.; software, E.-N.J., E.-L.P.; validation, E.-N.J., E.-L.P.; formal analysis, G.-O.M.J.; investigation, E.-N.J., E.-L.P.; resources, E.-N.J., E.-L.P.; data curation, G.-O.M.J.; writing—original draft preparation, G.-O.M.J., E.-N.J.; writing—review, editing, G.-O.M.J., O.-V.M., E.-N.J.; visualization, O.-V.M., R.M.; supervision, R.M. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee of Rey Juan Carlos University (protocol code 1504202110721, 15 April 2020) for studies involving humans.

Informed Consent Statement

Written informed consent has been obtained from the patients to publish this paper.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.

Conflicts of Interest

The authors declare no conflicts of interest.

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Applsci 14 10590 g001
Figure 1. Microimplant-assisted rapid palatal expansion (MARPE).
Figure 1. Microimplant-assisted rapid palatal expansion (MARPE).
Applsci 14 10590 g001
Table 1. Indicators.
Table 1. Indicators.
Indicator (Acronym) Description
MxWMaxillary widthDistance between the most external points of the maxillary cortical bone at the level of the upper right and left first molar furcas
EMExpansion morphologyShape of expansion of midpalatal suture; parallel, most anterior, or most posterior
HUs ANSHounsfield units in 1st regionHounsfield units in the anterior nasal spine
HUs MNSHounsfield units in 2nd regionHounsfield units in the junction between the midpalatal suture and transverse palatal suture (medium nasal spine)
HUs PNSHounsfield units in 3rd regionHounsfield units in the posterior nasal spine
Table 2. Intraclass correlation coefficiency.
Table 2. Intraclass correlation coefficiency.
ICC
MxWT0 (mm)0.999
MxWT1 (mm)0.993
MxWT0T1 (mm)0.999
ANS (HUs)0.988
MNS (HUs)0.991
PNS (HUs)0.972
Table 3. Descriptive analysis of variables in the total sample.
Table 3. Descriptive analysis of variables in the total sample.
Mean (SD)
Sample
n = 30
Age (years)23.90 (4.89)
MxWT0 (mm)55.45 (4.70)
MxWT1 (mm)58.05 (5.46)
MxWT0T12.61 ± 1.93
HUs ANS970.83 (234.74)
HUs MNS743.63 (297.44)
HUs PNS810.47 (224.49)
Note: M (Mean), SD (Standard deviation), MxWT0 (Maxillary Width T0), MxWT1 (Maxillary Width T1), HUs ANS (Hounsfield units in anterior nasal spine), HUs MNS (Hounsfield units in mid nasal spine), and HUs PNS (Hounsfield units in posterior nasal spine).
Table 4. Differences in bone densities in HUs in different maxillary regions at T0.
Table 4. Differences in bone densities in HUs in different maxillary regions at T0.
MSDtp
HUs ANS-HUs MNS227.20265.384.6890.000
HUs ANS-HUs PNS160.37228.123.8500.001
HUs MNS-HUs PNS−66.83271.01−1.3510.187
Note: M (Mean), SD (Standard deviation), t (Student’s t statistic), p (significance), HUs ANS (Hounsfield units in anterior nasal spine), HUs MNS (Hounsfield units in mid nasal spine), and HUs PNS (Hounsfield units in posterior nasal spine).
Table 5. Differences in success and failure groups for variables of age, MxWT0, MxWT1, MxWT0T1, ANS (HUs), MNS (HUs), and PNS (HUs).
Table 5. Differences in success and failure groups for variables of age, MxWT0, MxWT1, MxWT0T1, ANS (HUs), MNS (HUs), and PNS (HUs).
Opening of the Midpalatal Suture
Mean (SD)
Success
n = 15		Mean (SD)
Failure
n = 15		tpd
Age (years)22.13 (4.58)25.66 (4.67)−2.0920.046 *0.76
MxWT0 (mm)57.01 (3.01)53.88 (6.60)1.9040.0670.69
MxWT1 (mm)60.12 (3.37)55.98 (6.42)2.2110.035 *0.81
MxWT0T13.11 (1.56)2.09 (2.18)1.4600.1560.53
ANS (HUs)898.33 (231.24)1043.33 (222.26)−1.7510.9010.63
MNS (HUs)621.80 (143.55)865.46 (361.73)−2.4250.022 **0.88
PNS (HUs)722.01 (211.01)898.93 (207.61)−2.3150.028 **0.84
Note: MxWT0 (Maxillary Width T0), MxWT1 (Maxillary Width T1), ANS (HUs) (Hounsfield units in anterior nasal spine), MNS (HUs) (Hounsfield units in mid nasal spine), PNS (HUs) (Hounsfield units in posterior nasal spine), M (Mean), SD (Standard deviation), t (Student’s t statistic), p (significance), d (d, Cohen’s). Effect size is small ≈ 0.20; effect size is medium ≈ 0.50; effect size is large ≈ 0.80; * significance at 0.05; ** significance at 0.01.
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MDPI and ACS Style

Javier, E.-N.; María José, G.-O.; Pablo, E.-L.; Marta, O.-V.; Martín, R. Factors Affecting MARPE Success in Adults: Analysis of Age, Sex, Maxillary Width, and Midpalatal Suture Bone Density. Appl. Sci. 2024, 14, 10590. https://doi.org/10.3390/app142210590

AMA Style

Javier E-N, María José G-O, Pablo E-L, Marta O-V, Martín R. Factors Affecting MARPE Success in Adults: Analysis of Age, Sex, Maxillary Width, and Midpalatal Suture Bone Density. Applied Sciences. 2024; 14(22):10590. https://doi.org/10.3390/app142210590

Chicago/Turabian Style

Javier, Echarri-Nicolás, González-Olmo María José, Echarri-Labiondo Pablo, Olmos-Valverde Marta, and Romero Martín. 2024. "Factors Affecting MARPE Success in Adults: Analysis of Age, Sex, Maxillary Width, and Midpalatal Suture Bone Density" Applied Sciences 14, no. 22: 10590. https://doi.org/10.3390/app142210590

APA Style

Javier, E. -N., María José, G. -O., Pablo, E. -L., Marta, O. -V., & Martín, R. (2024). Factors Affecting MARPE Success in Adults: Analysis of Age, Sex, Maxillary Width, and Midpalatal Suture Bone Density. Applied Sciences, 14(22), 10590. https://doi.org/10.3390/app142210590

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