Biomechanics of conventional and miniscrew-assisted rapid palatal expansion.

Posterior Crossbite is a common condition resulting because of transverse maxillary deficiency. The growth of the craniofacial complex finishes first in the transverse dimension, followed by sagittal and vertical dimensions. Conventional rapid palatal expansion (RPE) appliances are commonly used to correct transverse maxillary deficiency. Although RPE is efficient in correcting posterior crossbite, it results in dental side effects such as buccal tipping of maxillary molars, root resorption, bone dehiscence, and relapse. Mini-implant-assisted RPE has been introduced to increase the skeletal effects of expansion especially in patients with increased maturation and greater interdigitation of midpalatal suture. This article will review the biomechanics of RPE and mini-implant-assisted RPE. Additionally, the different designs of MARPE and the long-term clinical effects of expansion appliances will also be discussed in detail.

Breathing changes following mini-implant-supported maxillary skeletal expander treatment in late adolescent or adult patients : Assessment of objective and subjective functional breathing changes.

PURPOSE: The aim of this study was to assess objective and subjective breathing changes in adult patients who underwent maxillary skeletal expansion with the mini-implant-supported maxillary skeletal expander (MSE). METHODS: Twenty-nine patients (mean age 18.1 ± 4.3 years) who underwent expansion using the MSE were compared pre- and posttreatment and with a control group (mean age 19.9 ± 2.6 years) to assess objective and subjective functional breathing changes. Objective measurements of the airway including peak nasal inspiratory flow (PNIF) and peak oral inspiratory flow (POIF) were measured utilizing the In-Check medical device (Clement Clarke, Harlow, United Kingdom). Patients reported subjective breathing assessment utilizing the visual analog scale (VAS). Intragroup comparisons were performed with Wilcoxon tests and intergroup comparison with Mann-Whitney U tests. Spearman correlation coefficients were calculated among the studied variables (P < 0.05). RESULTS: Following MSE treatment, there were significantly higher values for PNIF total (P < 0.0001), PNIF right (P < 0.0001), PNIF left (P < 0.0001), and POIF (P < 0.01) compared to pretreatment and control group results. Also, patients reported a significant decrease in troubled breathing as measured by the VAS for breathing through the right nostril (P < 0.01), left nostril (P < 0.001), and both nostrils (P < 0.01). Comparing the objective and subjective variables for both the pre-MSE or post-MSE groups, the results indicated no significant correlation between total PNIF and total VAS. However, the values had significant correlations between PNIF and VAS on each side when the patients were asked to block one nostril. CONCLUSIONS: Objective functional breathing measurements were increased immediately after treatment with MSE. Subjective functional breathing measurements changes were significantly higher after MSE treatment and compared with the control group. MSE presents a nonsurgical alternative to achieving orthopedic expansion in adult patients which may provide a benefit for patients with nasal airway obstruction.

A Retrospective Histological Study on Palatal and Gingival Mucosa Changes during a Rapid Palatal Expansion Procedure.

The most common inflammatory reactions in the oral mucosa are found at the gingival level. The treatment of these inflammations requires, first of all, the removal of the causative factor; often, this maneuver is sufficient. The aim of this retrospective study was to evaluate clinical and histopathological changes that occur in terms of gingival and palatal mucosa enlargement during palatal expansion treatment and their evolution during treatment. Twenty-five (n = 25) research participants, aged between thirteen and twenty-six years old, were examined in this retrospective study. At the end of the treatment, fragments of tissue from the affected level were obtained via incisional biopsy and sent to the histopathology laboratory for a specialized examination. The changes identified were specific to mechanical traumatic injuries, thus excluding hyperplasia from other etiologies (infectious, tumoral, or non-mechanical traumatic). The examined fragments showed hyperplasia. The histopathological examination revealed the mechanical character of the lesion, strengthening the causal relationship between the insertion of the expander and the occurrence of hyperplasia of the palatal mucosa. The type of palatal expander influenced the degree of inflammation, with the severity of hyperplasia being more pronounced in the case of mini-implant-anchored rapid palatal expander (MARPE) usage than in the case of tooth-borne rapid palatal expander (RPE) usage. The analysis of the distance between the expander and the palatal mucosa did not provide conclusive results; the incidence and severity of the reaction were variable in patients with the same distance between the expander and the palatal or gingival mucosa.

Digital workflow for mini-implant-assisted rapid palatal expander fabrication-a case report.

BACKGROUND: Non-surgical mini-implant assisted rapid palatal expansion, or midfacial skeletal expansion, is a paradigm-shifting concept that in recent years has expanded the envelope of orthopedic movement in the transverse direction for adult patients. Although adding mini-screws to a rapid palatal expander is not complicated, accurate and successful expansion strongly depends on the device's position and its relation to the resisting structures of the maxillofacial complex. CASE PRESENTATION: This article presents a digital workflow to locate the optimal position of the Midfacial Skeletal Expander (MSE) device in a CBCT-combined intraoral scan file and describes how to transfer the MSE position intra-orally with properly sized bands during the device fabrication. The complete digital workflow of MSE fabrication and its application for a Class III orthognathic surgical case is presented in detail. CONCLUSIONS: This report describes a completely digital process that can accurately position the MSE device according to the orientation and morphology of maxillary basal bone, which is crucial in adult cases demand maxillary expansion.

Long-term efficacy and stability of miniscrew-assisted rapid palatal expansion in mid to late adolescents and adults: a systematic review and meta-analysis.

BACKGROUND: The purpose of this study is to investigate the long-term efficacy and stability of Miniscrew-assisted Rapid Palatal Expansion (MARPE), including its primary outcomes, namely the nasomaxillary complex transverse skeletal and dental expansion, and related secondary outcomes. METHODS: Electronic databases and manual literature searches, up to October 31, 2022, were performed. The eligibility criteria were the following: studies on patients with transverse maxillary deficiency treated with MARPE in adults and adolescents over 13.5 years of age. RESULTS: Ultimately, twelve articles were included in the analysis, one prospective and eleven retrospective observational studies. Five studies showed a moderate risk of bias, while the remaining seven studies were at a serious risk of bias. The GRADE quality of evidence was very low. MARPE is an effective treatment modality for transverse maxillary deficiency (mean success rate: 93.87%). Patients showed increased mean in the skeletal and dental transverse expansion. The basal bone composition, mean alveolar bone and mean dental expansion accounted for 48.85, 7.52, and 43.63% of the total expansion, respectively. There was a certain degree of skeletal and dental relapse over time. MARPE could also cause dental, alveolar, and periodontal side effects, and have an impact on other craniofacial bones, upper airway, and facial soft tissue. CONCLUSIONS: MARPE is an effective treatment for transverse maxillary deficiency, with a high success rate and a certain degree of skeletal and dental relapse over time.

The short- and long-term changes of upper airway and alar in nongrowing patients treated with Mini-Implant Assisted Rapid Palatal Expansion (MARPE): a systematic review and meta-analysis.

OBJECTIVE: This study aims to assess the short- and long-term changes in the upper airway and alar width after mini-implant -assisted rapid palatal expansion (MARPE) in nongrowing patients. METHODS: Five electronic databases (PubMed, Scopus, Embase, Web of Science, and Cochrane Library) were searched up to 2 August, 2023 based on the PICOS principles. The main outcomes were classified into three groups: 1) nasal cavity changes, 2) upper airway changes and 3) alar changes. The mean difference (MD) and 95% confidence intervals (CI) were used to assess these changes. Heterogeneity tests, subgroup analyses, sensitivity analyses, and publication bias were also analyzed. RESULT: Overall, 22 articles were included for data analysis. Nasal cavity width (WMD: 2.05 mm; 95% CI: 1.10, 3.00) and nasal floor width (WMD: 2.13 mm; 95% CI: 1.16, 3.11) increased significantly. While palatopharyngeal volume (WMD: 0.29 cm3, 95% CI: -0.44, 1.01), glossopharyngeal volume (WMD: 0.30 cm3, 95% CI: -0.29, 0.89) and hypopharyngeal volume (WMD: -0.90 cm3; 95% CI: -1.86, 0.06) remained unchanged, nasal cavity volume (WMD: 1.24 cm3, 95% CI: 0.68, 1.81), nasopharyngeal volume (MD: 0.75 cm3, 95% CI: 0.44, 1.06), oropharyngeal volume (WMD: 0.61 cm3, 95% CI: 0.35, 0.87), and total volume of the upper airway (WMD: 1.67 cm3, 95% CI: 0.68, 2.66) increased significantly. Alar width (WMD: 1.47 mm; 95% CI: 0.40, 2.55) and alar base width (WMD: 1.54 mm; 95% CI: 1.21, 1.87) also increased. CONCLUSION: MARPE can increase nasal cavity width, nasal cavity volume, nasopharyngeal volume and oropharyngeal volume for nongrowing patients, but has no significant effect on hypopharyngeal volume. In addition, the alar width also increased. However, the studies included in this meta-analysis were mainly retrospective, nonrandomized and small in number, so the findings should be interpreted with caution and high-quality RCTs need to be studied.

Short-term outcomes in the upper airway with tooth-bone-borne vs bone-borne rapid maxillary expanders.

BACKGROUND: This study compared the area and minimal section of the nasal cavity, nasopharynx, oropharynx, and hypopharynx in cases treated with different methods of microimplant-assisted expansion. METHODS: Based on a pilot study to calculate the sample size, 30 patients with transverse maxillary deficiency over 14 years of age were retrospectively selected. These patients had received two different types of microimplant-assisted maxillary expansion treatment (MARPE and BAME). The patient underwent Cone-Beam computed tomography (CBCT) before and after treatment (mean time 1.5 months) with MARPE or BAME and upper airway measurements (volume and minimum cross-sectional area) were taken to assess upper airways changes and compare changes between the groups. A paired sample t-test was performed to evaluate the T0-T1 change of airway measurements obtained with MARPE and BAME, and a student t-test to compare changes in airway measurements between MARPE and BAME. RESULTS: This investigation shows a statistically significant increase in total nasopharyngeal airway volume (0.59 ± 1.42 cm3; p < 0.01), total oropharyngeal airway volume (3.83 ± 7.53 cm3; p < 0.01) and minimum oropharyngeal cross-section (53.23 ± 126.46 mm2; p < 0.05) in all cases treated with micro-screw assisted expansion. The minimal cross-sectional area of the oropharynx ((79.12 ± 142.28 mm2; p < 0.05) and hypopharynx (59.87 ± 89.79 mm2; p < 0.05) showed significant changes for cases treated with BAME. As for the comparison between cases treated with MARPE and BAME, no differences in upper airway changes have been observed, except for the minimum cross-sectional area of the nasal cavity, which increases for MARPE (52.05 ± 132.91 mm2) and decreases for BAME (-34.10 ± 90.85 mm2). CONCLUSIONS: A significant increase in total area and minimal section at the level of nasopharynx and oropharynx was observed in cases treated with BAME. Regarding the comparison of MARPE and BAME treatments, no differences were found in the total airway volume and minimal section in upper airway except for the minimum cross section of the nasal cavity that increases for MARPE and decreases for BAME.

Changes in Molar Tipping and Surrounding Alveolar Bone with Different Designs of Skeletal Maxillary Expanders.

This study compared the buccolingual angulation (BLA) of the upper and lower first permanent molars before and after using the different methods of microimplant-assisted expansion in adults and its influence on bone insertion loss. METHODS: Cone-beam computed tomography scans taken before and after the expansion in 36 patients (29.9 ± 9.4 years) were used to assess dental and periodontal changes and compare changes between the groups. RESULTS: This research shows a statistically significant increase in the BLA of the upper first molars. An increase of the BLA of the lower molars is also observed in MARPE. Regarding the comparison between cases treated with MARPE (4.42° ± 10.25°; 3.67° ± 9.56°) and BAME (-0.51° ± 4.61°; 2.34° ± 4.51°), it was observed that upper molar torque increased significantly less in cases treated with BAME. In cases with CWRU < 96° at T0, a slight bone insertion gain was observed at T1, whereas if CWRU ≥ 96°, a slight bone insertion loss was observed. Regarding the labial cortical bone loss, a slight gain of CBW was observed in all cases. This labial cortical enlargement (T0-T1) is greater in cases where the CWRU < 96° at T0. CONCLUSIONS: Patients treated with MARPE show torque increase in the teeth selected to support the expansion appliance compared to cases treated with BAME. In cases where the BLA at T0 < 96°, an increase in thickness and cortical insertion is observed in the upper molars after treatment with disjunction appliances assisted with microscrews.

Influence of miniscrew-assisted rapid palatal expansion (MARPE) on the interdental papilla height of maxillary central incisors.

OBJECTIVES: To evaluate the influence of miniscrew-assisted rapid palatal expansion (MARPE) on the interdental papilla height of maxillary central incisors. MATERIALS AND METHODS: Patients who completed MARPE treatment at the Radboud University Medical Center between 2018 and 2021 were included in this retrospective study. The papilla height between the maxillary central incisors was evaluated on frontal intraoral photographs taken before expansion (T0) and 1.5 years after MARPE treatment (T1) using the Jemt classification. The difference in Jemt score at T0 and T1 was the primary outcome variable. In addition, gender, age, Angle classification, MARPE duration, midpalatal suture maturation stage, maximal central diastema (MCD) immediately after expansion, crown width to length ratio (W/L), pretreatment overlap of maxillary central incisors, and the distance between the approximal contact point of the central incisors and the bone crest (CP-B) were also record. RESULTS: Twenty-two patients were included (2 men, 20 women, mean age 27.3 ± 8.8 years) and 4 patients (18%) showed a significant reduction in the Jemt score following MARPE (p = 0.04), indicating papilla recession. Interdental papilla recession was significantly associated with the increase of CP-B (p = 0.02), smaller W/L (p < 0.01), overlapping of maxillary central incisors (p < 0.01), and smaller MCD immediately after expansion (p = 0.02). CONCLUSIONS: One and a half years after MARPE, 18% of patients exhibited mild recession of papilla height of the maxillary central incisors. Overlapping and smaller W/L of maxillary central incisors were prognostic factors for interdental papilla recession. CLINICAL RELEVANCE: Clinicians have to be aware of and inform the patients about the occurrence of papilla recession following MARPE.

What is the impact of miniscrew-assisted rapid palatal expansion on the midfacial soft tissues? A prospective three-dimensional stereophotogrammetry study.

OBJECTIVES: To evaluate the midfacial soft tissue changes of the face in patients treated with miniscrew-assisted rapid palatal expansion (MARPE). MATERIALS AND METHODS: 3D facial images and intra-oral scans (IOS) were obtained before expansion (T0), immediately after completion of expansion (T1), and 1 year after expansion (T2). The 3D images were superimposed and two 3D distance maps were generated to measure the midfacial soft tissue changes: immediate effects between timepoints T0 and T1 and overall effects between T0 and T2. Changes of the alar width were also measured and dental expansion was measured as the interpremolar width (IPW) on IOS. RESULTS: Twenty-nine patients (22 women, 7 men, mean age 25.9 years) were enrolled. The soft tissue in the regions of the nose, left of philtrum, right of philtrum, and upper lip tubercle demonstrated a statistically significant anterior movement of 0.30 mm, 0.93 mm, 0.74 mm, and 0.81 mm, respectively (p < 0.01) immediately after expansion (T0-T1). These changes persisted as an overall effect (T0-T2). The alar width initially increased by 1.59 mm, and then decreased by 0.08 mm after 1 year, but this effect was not significant. The IPW increased by 4.58 mm and remained stable 1 year later. There was no significant correlation between the increase in IPW and alar width (r = 0.35, p = 0.06). CONCLUSIONS: Our findings indicate that MARPE results in significant but small changes of the soft tissue in the peri-oral and nasal regions. However, the clinical importance of these findings is limited. CLINICAL RELEVANCE: MARPE is an effective treatment modality to expand the maxilla, incurring only minimal and clinically insignificant changes to the midfacial soft tissues.

Maxillary expansion in nongrowing patients. Conventional, surgical, or miniscrew-assisted, an update.

Maxillary transverse deficiency can occur in various clinical dentoskeletal deformities and include unilateral or bilateral posterior crossbite, narrow, tapering, or high palatal arch. The development of temporary anchorage devices led to a new generation of tooth-bone-borne expansion appliance using two or four screws to apply the mechanical forces to the bone and reduce the stress to the anchored teeth. The aim of these new devices is to reduce the adverse dentoalveolar effect and achieve more skeletal expansion than conventional tooth-borne rapid palatal expansion. This article reviews the age limitation and complication and soft tissue change of nonsurgical maxillary expansion. We discuss the approach of surgical maxillary expansion with maxillary skeletal expander device. The clinical case will show the benefit of nonsurgical and surgical tooth-bone-borne rapid palatal expansion.

Skeletal and dentoalveolar effects of miniscrew-assisted rapid palatal expansion based on the length of the miniscrew: a randomized clinical trial.

OBJECTIVES: To compare skeletal and dentoalveolar changes of miniscrew-assisted rapid palatal expansion (MARPE) according to the length of the miniscrews. MATERIALS AND METHODS: This two-arm parallel-randomized controlled trial included 32 adult patients aged 19-35 years who received orthodontic treatment with MARPE. Patients were allocated to two groups, group long (L) and short (S), through block randomization according to the length of the miniscrews installed in MARPE. Cone-beam computed tomography was performed before expansion and after removal of the MARPE; superimposition of the images was conducted. The primary outcome included the amount of bone expansion and the change in the inclination of the anchorage teeth. The secondary outcome included the success rate of midpalatal suture opening and stability of the miniscrews. Blinding was performed during outcome assessment. RESULTS: The final sample comprised 31 patients. There was no significant difference in patient characteristics between group L (n = 16) and group S (n = 15). The change in the width of the processus zygomaticus (P = .010) and ectocanine (P = .001) was significantly higher in group L. A significantly higher success rate of the posterior miniscrews was seen in group L (P = .024). There was no statistically significant difference in the success rate of suture separation or change in tooth inclination. Notable complications were not reported. CONCLUSIONS: MARPE with longer miniscrews can increase the amount of expansion of the maxillary basal bone and canine alveolar bone. Although it also aided in miniscrew stability, it did not guarantee successful midpalatal suture separation.

Clinical advances in maxillary skeletal expansion and introduction of a new MARPE concept.

BACKGROUND: Transverse maxillary deficiency, typically characterized by the clinical manifestations of unilateral or bilateral crossbite, is a common orthodontic discrepancy. The primary goal of maxillary expansion should be to obtain a nearly maximum width increase in the basal bone of the constricted maxilla and to avoid the dental expansion of the anchor teeth. The introduction of miniscrew anchorage-supported rapid maxillary expansion (MARPE) devices has helped increase the feasibility of obtaining nonsurgical transverse correction in late adolescents and young adults with optimum orthopedic effects. However, the success rate of MARPE shows a negative correlation with age. Although MARPE offers an effective method for correcting a transverse skeletal deficiency, given the appliance cost and increased risk for complications, it could present challenges for adult patients and practitioners in daily practice. AIMS: In this article, current advances in maxillary skeletal expansion are summarized, and a new MARPE concept is introduced. CONCLUSION: The new MARPE design offers several advantages to other existing methods: (1) it can be installed directly to the patient in the clinical setting with no additional laboratory waiting times. (2) It is purely a bone-borne appliance. (3) The appliance is designed to be placed in the thickest part of the anterior palate to maximize the cortical and trabecular bone support. (4) Allows for bicortical placement of the miniscrews with no perforations in the nasal floor. Finally, (5) offers an esthetic and minimalistic approach to maxillary skeletal expansion in late adolescent and adult patients.

Evaluation of miniscrew-assisted rapid palatal expansion success by comparing width of circummaxillary sutures before expansion in adult male patients.

OBJECTIVES: To investigate the relationship between circummaxillary sutures and miniscrew-assisted rapid palatal expansion (MARPE) success in adult male patients and to evaluate the correlation between the width of the sutures and the maxilla expansion ratio. MATERIALS AND METHODS: This retrospective study comprised 40 adult male patients treated with MARPE divided into a separation group (N = 20, mean age, 21.9 years) consisting of subjects with midpalatal suture opening and a nonseparation group (N = 20, mean age, 21.7 years) consisting of subjects with no midpalatal suture opening. Cone-beam computed tomography images were obtained before MARPE expansion for both groups and after expansion for the separation group. Vertical and horizontal skeletal relationships, palate length, and widths of 10 circummaxillary sutures before expansion were compared. The correlation between maxilla expansion ratio (jackscrew expansion to maxillary expansion ratio) and circummaxillary suture widths was also analyzed in the separation group. RESULTS: There were no significant differences in age, vertical and horizontal skeletal relationships, and palate length between the two groups. Zygomaticomaxillary, pterygomaxillary, midpalatal, and transverse palatine sutures showed significantly greater width in the separation group (P < .05). The zygomaticomaxillary suture showed the greatest difference (Δ = 0.36 mm) between the groups. The zygomaticomaxillary and pterygomaxillary sutures showed significant positive correlation with the maxilla expansion ratio (P < .01). CONCLUSIONS: In adult male patients, greater circummaxillary suture widths before MARPE expansion, especially zygomaticomaxillary and pterygomaxillary sutures, resulted in a better chance of successful suture separation and more maxillary expansion.

Does MARPE therapy have effects on intracranial pressure? a clinical study.

BACKGROUND: We aimed to evaluate possible intracranial pressure (ICP) changes caused by screw activations during active microimplant-assisted rapid palatal expansion (MARPE) therapy of post-pubertal individuals by measuring the optic nerve sheath diameter (ONSD) under ultrasonography (US) guidance. METHODS: This study's participants comprised 15 patients (7 males, 8 females) with posterior crossbite and a mean age of 16.7 years (14.25-20.08 years). The Maxillary Skeletal Expander (MSE) appliance was used to perform MARPE in all patients. Their vital signs (heart rate, mean arterial pressure (MAP), and peripheral oxygen saturation (SpO2)) were recorded. The ONSD was measured by US immediately before the first screw activation (T0), and the measurements were repeated 1 min (T1) and 10 min (T2) after the first activation. In the last session of active MARPE therapy, the same measurement protocol was performed as in the first activation session (T3, T4, and T5). The patients' perceptions of pain during the screw activation were also noted at T1 and T4 using a four-category verbal rating scale (VRS-4). The significant differences among different time intervals performed with the Friedman test (for all tested variables; SpO2, MAP, Heart Rate, VRS-4 and ONSD). Spearman correlation test was used for VRS-4 and ONSD comparisons. The statistical significance level was accepted as p < 0.05. RESULTS: The ONSD values ​​(T1 and T4) relatively increased within 1 min after screw activation but did not reach a statistically significant level (p > 0.05). There was also no significant difference between the initial (T0) and the final (T5) ONSD values ​​during the active MARPE therapy (p > 0.05). CONCLUSION: There is no changes or alterations in intracranial pressure in late adolescents during active MARPE therapy.

Nasomaxillary Expansion by Endoscopically-Assisted Surgical Expansion (EASE): An airway centric approach / Expansion nasomaxillaire chirurgicale assistée par endoscopie (EASE) : une approche centrée surles voies respiratoires

Introduction: The aim of this study was to analyze the skeletal, dental and airway changes with endoscopically assisted surgical expansion (EASE) to widen the nasomaxillary complex for the treatment of sleep apnea in adults. Methods: One hundred and five consecutive patients underwent EASE. Cone beam computed tomography (CBCT) was conducted preoperatively and within four weeks after the completion of the expansion process. Computational fluid dynamic (CFD) analysis was performed on 20 randomly selected patients to assess airway flow changes. Results: One hundred patients (67 males) with the mean age of 35.0±13.5 years (17-64 years) had completed pre- and post-expansion imaging. Ninety-six patients (96%) had successful expansion defined as separation of the midpalatal suture at least 1 mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal cavity expansion was 3.12±1.11 mm at ANS, 3.64±1.06 mm at first molar and 2.39±1.15 mm at PNS. The zygoma expansion was 2.17±1.11 mm. The ratio of dental expansion to skeletal expansion was 1.23:1 (3.83 mm:3.12 mm) at canine and 1.31:1 (4.77 mm:3.64 mm) at first molar. CFD airway simulation showed a dynamic change following expansion throughout the airway. The mean negative pressure improved in the nasal airway (from -395.5±721.0 to -32.7±19.2 Pa), nasopharyngal airway (from -394.2±719.4 to -33.6±18.5 Pa), oropharyngeal airway (from -405.9±710.8 to -39.4±19.3 Pa) and hypopharyngeal airway (from -422.6±704.9 to -55.1±33.7 Pa). The mean airflow velocity within the nasal airway decreased from 18.8±15.9 to 7.6±2.0 m/s and the oropharyngeal airway decreased from 4.2±2.9 to 3.2±1.2 m/s. The velocity did not change significantly in the nasopharyngeal and hypopharyngeal regions. Conclusions: EASE results in expansion of the midpalatal suture from the ANS to PNS with a nearly pure skeletal movement of minimal dental effect. The expansion of the nasomaxillary complex resulted in the widening of the nasal sidewall throughout the nasal cavity. The improved air flow dynamics was demonstrated by CFD simulation.

Introduction: L'objectif de cette étude était d'analyser les modifications obtenues au niveau du squelette, des dents et des voies respiratoires lors d'une expansion nasomaxillaire chirurgicale assistée par endoscopie (EASE), visant à élargir le complexe nasomaxillaire pour le traitement de l'apnée du sommeil chez des adultes. Méthodes: Cent cinq patients consécutifs ont subi une EASE. Une tomographie à faisceau conique (CBCT) a été réalisée en préopératoire et dans les quatre semaines suivant la fin du processus d'expansion. Une analyse de la dynamique des fluides computationnelle (DFC) a été réalisée sur vingt patients sélectionnés au hasard pour évaluer les modifications du débit de leurs voies respiratoires. Résultats: Un bilan d'imagerie pré- et post-expansion a été réalisé chez cent patients (dont 67 hommes) d'un âge moyen de 35,0 ± 13,5 ans (17-64 ans). Quatre-vingt-seize patients (96 %) ont bénéficié d'une expansion réussie, définie comme une séparation de la suture médiopalatine d'au moins 1 mm, de l'épine nasale antérieure (ENA) à l'épine nasale postérieure (ENP). L'expansion de la cavité nasale était de 3,12 ± 1,11 mm au niveau de l'ENA, de 3,64 ± 1,06 mm au niveau de la première molaire et de 2,39 ± 1,15 mm au niveau de l'ENP. L'expansion zygomatique était de 2,17 ± 1,11 mm. Le rapport entre l'expansion dentaire et l'expansion squelettique était de 1,23 : 1 (3,83 mm : 3,12 mm) au niveau de la canine et de 1,31 : 1 (4,77 mm : 3,64 mm) au niveau de la première molaire. Après l'expansion, la simulation des voies respiratoires par DFC a montré un changement dynamique au niveau de l'ensemble des voies respiratoires. La pression négative moyenne s'est améliorée dans les voies nasales (de -395,5 ± 721,0 à -32,7 ± 19,2 Pa), les voies nasopharyngiennes (de -394,2 ± 719,4 à -33,6 ± 18,5 Pa), les voies aériennes oropharyngées (de -405,9 ± 710,8 à -39,4 ± 19,3 Pa) et les voies aériennes hypopharyngées (de -422,6 ± 704,9 à -55,1 ± 33,7 Pa). La vitesse moyenne du flux d'air dans les voies nasales a diminué de 18,8 ± 15,9 à 7,6 ± 2,0 m/s et de 4,2 ± 2,9 à 3,2 ± 1,2 m/s dans les voies oropharyngées. La vitesse n'a pas changé de manière significative dans les régions nasopharyngienne et hypopharyngienne. Conclusions: L'EASE entraîne une expansion de la suture médiopalatine, de l'ENA jusqu'à l'ENP avec un mouvement squelettique presque pur et un effet dentaire minimal. L'expansion du complexe nasomaxillaire a entraîné l'écartement des parois nasales latérales dans toute la cavité nasale. L'amélioration de la dynamique du flux d'air a été démontrée par une simulation DFC.

What is the Oral Health-related Quality of Life following Miniscrew-Assisted Rapid Palatal Expansion (MARPE)? A prospective clinical cohort study.

BACKGROUND: Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is a non-surgical orthodontic treatment for transverse maxillary deficiency. This study aimed to investigate the Oral Health-related Quality of Life (OHRQoL) and pain perception of patients undergoing MARPE treatment. METHODS: 42 consecutive patients (9 men, 33 women) from the age of 16 onwards (mean: 27.4 ± 9.3 years; range 17.1-55.7 years) who received a MARPE treatment were included. OHRQoL was assessed with the short form of the Oral Health Impact Profile (OHIP-14) questionnaire. Patients filled out the questionnaire at baseline (T0) and weekly during the expansion phase (P1) and in the post-expansion phase (P2). Pain intensity was assessed with a Visual Analogue Scale (VAS) questionnaire and filled out daily during expansion, along with a question on the intake of analgesics. The mean weekly and total OHIP-score and OHIP-score per domain were calculated at T0, P1 and P2, as well as mean weekly and total VAS-scores for average pain, maximum pain and analgesics intake during P1. Kruskal-Wallis tests were used to test for differences in OHIP between T0, P1 and P2. The level of significance was set at 0.05. RESULTS: The mean OHIP-score was 10.86 ± 9.71 at T0 and increased to 17.18 ± 10.43 during P1 (p < 0.001), after which it returned to pre-expansion levels, 9.27 ± 7.92 (p = 0.907) during P2. At the domain level, there was a statistically significant increase in OHIP-score at P1 for functional limitation, physical pain, psychological discomfort and social disability. The mean VAS-score for average pain during expansion was 16.00 ± 19.73 mm. Both OHIP-score (25.00 ± 10.25), average pain (33.72 ± 16.88 mm), maximum pain (44.47 ± 17.99 mm) and analgesics intake (59%) were highest at initiation of the expansion and decreased by the end of expansion. CONCLUSIONS: MARPE is a generally well-tolerated expansion treatment. A temporary decline in OHRQoL and moderate pain are present at the start of expansion, followed by a recovery of OHRQoL and very mild pain during the rest of treatment. Clinicians should be aware of the effects of MARPE on patients' quality of life and manage the expected discomfort and impediments with adequate communication and patient education.

Persistent pediatric obstructive sleep apnea treated with skeletally anchored transpalatal distraction / SAOS pédiatrique persistant traité par distraction transpalatine à ancrage squelettique

Introduction: The aim of this study was to evaluate the impact of nasomaxillary expansion using skeletally anchored transpalatal distraction (TPD) in children without transverse maxillary deficiency that were previously treated by rapid palatal expansion (RPE). Materials and Methods: Twenty-nine consecutive children were treated by TPD. Twenty-five children, aged 10-16 years completed pre- and post-operative clinical evaluations, questionnaires (OSA-18), cone beam computed tomography (CBCT), and polysomnography (PSG). The pre- and post-operative CBCT data were used to reconstruct the 3-dimensional shape of the upper airway. Two measures of airflow function (pressure and velocity) were simulated by using computational fluid dynamics (CFD) at four different airway segments (nasal, nasopharyngeal, oropharyngeal and hypopharyngeal). Results: Twenty-three patients (92%) experienced improvement based on PSG. The apnea hypopnea index (AHI) improved from 6.72 ± 4.34 to 3.59 ± 5.11 (p<0.001) events per hour. Clinical symptoms based on OSA-18 scores were improved in all patients. Twenty-five patients (100%) had successful expansion defined as separation of the midpalatal suture at least 1mm from anterior nasal spine (ANS) to posterior nasal spine (PNS). The nasal sidewall widening was 2.59 ± 1,54 mm at canine, 2.91 ± 1,23 mm at first molar and 2.30 ± 1,29 mm at PNS. The ratio of dental expansion to nasal expansion was 1.12:1 (2.90mm:2.59mm) at canine and 1.37:1 (3.98mm:2.91mm) at first molar. The nasal airflow pressure reduced by 76% (-275.73 to -67.28 Pa) and the nasal airflow velocity reduced by over 50% (18.60 to 8.56 m/s). Conclusions: Nasomaxillary expansion by skeletally anchored TPD improves OSA in children without transverse maxillary deficiency that were previously treated by RPE. A nearly parallel anterior-posterior opening of the mid-palatal suture achieves enlargement of the entire nasal passage with improvement of the airflow characteristics in the nasal and pharyngeal airway. The improved airflow characteristic is significantly correlated with the improved polysomnographic findings, thus demonstrating that nasomaxillary expansion in previously expanded patients is a viable treatment option.

Introduction: L'objectif de cette étude était d'évaluer l'impact de l'expansion nasomaxillaire à l'aide d'une distraction transpalatine (DTP) à ancrage squelettique chez des enfants sans insuffisance maxillaire transversale et qui ont été précédemment traités par expansion palatine rapide (EPR). Matériels et méthodes: Vingt-neuf enfants enrôlés consécutivement ont été traités par DTP. Vingt-cinq enfants, âgés de 10 à 16 ans, ont été soumis à des évaluations cliniques pré- et postopératoires, des questionnaires (OSA-18), une tomographie à faisceau conique (CBCT) et une polysomnographie (PSG). Les données CBCT pré- et postopératoires ont été utilisées pour reconstruire la forme tridimensionnelle des voies aériennes supérieures. Deux mesures des caractéristiques d'écoulement de l'air (pression et vitesse) ont été simulées en utilisant la dynamique des fluides computationnelle (DFC) dans quatre segments différents des voies aériennes (nasal, nasopharyngé, oropharyngé et hypopharyngé). Résultats: Vingt-trois patients (92 %) ont bénéficié d'une rapide amélioration objectivée par la PSG. L'indice d'apnée-hypopnée (IAH) est passé de 6,72 ± 4,34 à 3,59 ± 5,11 (p<0,001) événements par heure. Les symptômes cliniques évalués avec les scores du questionnaire OSA-18 se sont améliorés chez tous les patients. Pour les vingt-cinq patients (100 %), l'expansion a été réussie, selon le critère d'une séparation de la suture médiopalatine d'au moins 1 mm, de l'épine nasale antérieure (ENA) jusqu'à l'épine nasale postérieure (ENP). L'élargissement de la distance entre les parois nasales latérales était de 2,59 ± 1,54 mm au niveau de la canine, de 2,91 ± 1,23 mm au niveau de la première molaire et de 2,30 ± 1,29 mm à l'épine nasale postérieure. Le rapport entre l'expansion dentaire et l'expansion nasale était de 1,12:1 (2,90 mm:2,59 mm) au niveau de la canine et de 1,37:1 (3,98 mm:2,91 mm) au niveau de la première molaire. La pression du flux d'air nasal a diminué de 76 % (-275,73 à -67,28 Pa) et la vitesse du flux d'air nasal a diminué de plus de 50 % (18,60 à 8,56 m/s). Conclusions: L'expansion nasomaxillaire à l'aide d'une distraction transpalatine à ancrage squelettique améliore le SAOS chez les enfants sans déficit maxillaire transverse et qui ont été auparavant traités par EPR. Une ouverture antéro-postérieure et presque parallèle de la suture médiopalatine permet d'élargir l'ensemble du passage nasal et d'améliorer les caractéristiques du flux d'air dans les voies aériennes nasales et pharyngées. L'amélioration des caractéristiques de l'écoulement d'air est significativement corrélée à l'amélioration des résultats polysomnographiques, démontrant ainsi que l'expansion nasomaxillaire chez des patients précédemment traités par EPR est une option thérapeutique viable.

Maxillomandibular Advancement for OSA: A 25-year perspective / Expansion maxillaire chirurgicale et non chirurgicale : modèles d'expansion, complications et échecs

OBJECTIVE: The focus of this report is to analyze the pattern of maxillary expansion and complications in patients following surgical and non-surgical maxillary expansion presented for evaluation and second opinion. MATERIALS AND METHODS: During a 30-months period, 28 patients presented for second opinion following maxillary expansion performed elsewhere. The indication for treatment was obstructive sleep apnea (OSA). All patients reported a lack of symptomatic improvements and problems associated with the treatment. Clinical examination with pre- and post-expansion cone beam computed tomography (CBCT), and treatment photographs were analyzed. RESULTS: Complete clinical records and CBCT were available in 22 patients for analysis. Six patients had undergone surgical expansion with distraction osteogenesis maxillary expansion (DOME), and 16 patients had undergone a variety of non-surgical expansion with different appliances. All the DOME patients had anterior nasal spine (ANS) separation without posterior nasal spine (PNS) separation. Diastema ranging between 10-16 mm was noted in the DOME patients, and the ratio of anterior diastema to ANS separation was between 2:1 to 3:1. Bone defects existed between the central incisors at 18 months or beyond following DOME in all the patients despite bone grafting attempts in four patients. Anterior gingival recession occurred in two patients and four incisor teeth required endodontic therapy with long-term guarded prognosis. Sixteen patients underwent non-surgical maxillary expansion with four different appliances, including anterior growth guidance appliance (AGGA), daytime-nighttime appliance (DNA), advanced lightwire functionals appliance (ALF), and mini-screw assisted rapid palatal expansion (MARPE). The midpalatal suture did not separate in any of the 16 patients, and the expansion pattern was purely dental and dentoalveolar in nature. Lateral dental tipping, thinning of the labial/buccal alveolar bone with gingival recession were noted in 10 patients. Significant mobility of the maxillary anterior teeth due to vertical and horizontal bone loss was noted in the five patients that underwent AGGA treatment. CONCLUSIONS: Different maxillary expansion methods are currently being performed with varying outcomes. Critical analyses of these methods are needed to determine their impact and whether the desired outcomes are achieved.

OBJECTIF: L'objectif de ce rapport est d'analyser, chez des patients venus consulter pour évaluation et deuxième avis, le mode d'expansion maxillaire et les complications survenues après une expansion maxillaire chirurgicale ou non chirurgicale. MATÉRIELS ET MÉTHODES: Au cours d'une période de 30 mois, 28 patients se sont présentés pour un deuxième avis, après une expansion maxillaire. L'indication du traitement était l'apnée obstructive du sommeil (AOS). Tous les patients ont fait état d' un manque d'amélioration de leurs symptômes et de problèmes liés au traitement. Les auteurs ont analysé les examens cliniques, les tomographies à faisceau conique (CBCT) réalisées avant et après l'expansion et les photographies prises au cours du traitement. RÉSULTATS: Les dossiers cliniques complets et les CBCT de 22 patients ont été recueillis pour être étudiés. Six patients avaient subi une expansion chirurgicale du type expansion maxillaire par distraction osseuse (DOME) et 16 patients avaient subi une expansion parmi plusieurs types d'expansions non chirurgicales, conduites au moyen de différents dispositifs. Tous les patients DOME présentaient une séparation de l'épine nasale antérieure (ENA) sans séparation de l'épine nasale postérieure (ENP). Un diastème de 10 à 16 mm a été observé chez les patients DOME et le rapport entre le diastème antérieur et la séparation de l'ENA était de 2:1 à 3:1. Des défauts osseux existaient entre les incisives centrales, à 18 mois ou plus après la DOME, chez tous les patients malgré des tentatives de greffe osseuse chez quatre d'entre eux. Une récession gingivale antérieure est apparue chez deux patients et l'état de quatre incisives a requis un traitement endodontique, dont le pronostic à long terme était réservé.. Seize patients ont subi une expansion maxillaire non chirurgicale conduite au moyen de quatre appareils différents, dont l'appareil de guidage de la croissance antérieure (AGGA), l'appareil jour-nuit (DNA), l'appareil fonctionnel évolué avec fil léger (ALF) et l'expansion palatine rapide assistée par minivis (MARPE). La suture médiopalatine ne s'est séparée chez aucun des 16 patients, et le schéma d'expansion était de nature purement dentaire et dento-alvéolaire. Une vestibuloversion des secteurs dentaires latéraux, un amincissement de l'os alvéolaire vestibulaire avec l'apparition de récessions gingivales ont été observés chez 10 patients. Une mobilité significative des dents antérieures maxillaires, due à une perte osseuse verticale et horizontale, a été notée chez les cinq patients qui ont subi un traitement avec l'AGGA. CONCLUSIONS: Différentes méthodes d'expansion maxillaire sont actuellement pratiquées avec des résultats variables. Des analyses critiques de ces méthodes sont nécessaires pour évaluer leur impact et déterminer si elles permettent d'obtenir les résultats souhaités.

Efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults with the Dutch Maxillary Expansion Device: a prospective clinical cohort study.

OBJECTIVES: To provide a higher degree of evidence on the efficacy of Miniscrew-Assisted Rapid Palatal Expansion (MARPE) in late adolescents and adults, thereby applying the Dutch Maxillary Expansion Device (D-MED). MATERIALS AND METHODS: D-MED was developed as an individualized, 3D-designed, and fabricated MARPE appliance supported by 4 palatal miniscrews. Patients from the age of 16 onwards with transverse maxillary deficiency were enrolled consecutively. Pre-expansion and immediate post-expansion CBCTs and intra-oral scans were acquired and measurements of skeletal, alveolar, and dental expansion as well as dental and periodontal side-effects were performed. RESULTS: Thirty-four patients were enrolled (8 men, 26 women) with mean age 27.0 ± 9.4 years. A success rate of 94.1% was achieved (32/34 patients). The mean expansion duration, or mean observation time, was 31.7 ± 8.0 days. The mean expansion at the maxillary first molars (M1) and first premolars (P1) was 6.56 ± 1.70 mm and 4.19 ± 1.29 mm, respectively. The expansion was 60.4 ± 20.1% skeletal, 8.1 ± 27.6% alveolar, and 31.6 ± 20.1% dental at M1 and 92.2 ± 14.5% skeletal, 0.0 ± 18.6% alveolar, and 7.8 ± 17.7% dental at P1, which was both statistically (p < 0.001) and clinically significant. Buccal dental tipping (3.88 ± 3.92° M1; 2.29 ± 3.89° P1), clinical crown height increase (0.12 ± 0.31 mm M1; 0.04 ± 0.22 mm P1), and buccal bone thinning (- 0.31 ± 0.49 mm M1; - 0.01 ± 0.45 mm P1) were observed, while root resorption could not be evaluated. CONCLUSIONS: MARPE by application of D-MED manifested its efficacy in a prospective clinical setting, delivering a high amount of skeletal expansion with limited side-effects in late adolescents and adults. CLINICAL RELEVANCE: Higher quality evidence is supportive of MARPE as a safe and successful non-surgical treatment option for transverse maxillary deficiency.