Annali di Stomatologia | 2026; 17(2): 425-437

ISSN 1971-1441 | DOI: 10.59987/ads/2026.2.425-437

Articles

Miniscrew-assisted rapid palatal expansion in the treatment of maxillary transverse deficiency: a systematic review

Claudia Theodora Truppa¹, Lisa Bertini², Riccardo Carullo², Elisa Cesarini³, Arianna Viarchi^1*

¹Department of Life, Health and Environmental Sciences, University of L’Aquila, L’Aquila, Italy

²DDS Private Practice, Perugia, Italy

³Dentistry School, University of Perugia, Perugia, Italy

^*Corresponding author: Arianna Varchi - arianna.viarchi@graduate.univaq.it

Article History

Received: May 3, 2026

Accepted: June 24, 2026

Published: June 30, 2026

Abstract

Aim

To evaluate the clinical and biomechanical effects of MARPE in the treatment of maxillary transverse deficiency, focusing on skeletal expansion, dentoalveolar changes, periodontal outcomes, airway modifications, and treatment success in adolescent and adult patients.

Methods

The review was conducted in accordance with the PRISMA 2020 guidelines. A systematic electronic search was performed in the PubMed/MEDLINE database for studies published between January 2021 and February 2026. The focused question was structured using the PECO framework. Human clinical studies evaluating MARPE or MSE appliances in patients with maxillary transverse deficiency were considered eligible. Risk of bias was assessed using the RoB 2.0 and ROBINS-I tools.

Results

The electronic search identified 54 records. After screening and full-text evaluation, 11 studies met the eligibility criteria and were included in the qualitative synthesis. Most investigations reported successful opening of the midpalatal suture and significant transverse skeletal expansion after MARPE treatment, even in skeletally mature patients. CBCT analyses showed skeletal expansion values of approximately 4–5 mm, with fewer dentoalveolar side effects compared with conventional rapid palatal expansion. Several studies also reported increases in nasal cavity dimensions and upper airway volume following treatment. Although buccal dental tipping and alveolar remodeling were observed, severe periodontal complications were uncommon. The overall quality of the evidence ranged from low to moderate due to methodological heterogeneity and the limited number of randomized clinical trials.

Conclusions

Within these limitations, MARPE appears to be an effective treatment option for maxillary transverse deficiency in selected adolescent and adult patients, providing clinically significant skeletal expansion while reducing dentoalveolar side effects. However, further high-quality prospective studies and randomized clinical trials are needed to clarify long-term stability, periodontal effects, and the orthopedic predictability of MARPE treatment.

Keywords: MARPE; MSE; maxillary transverse deficiency; skeletal expansion; rapid palatal expansion; miniscrew-assisted expansion; CBCT.

Introduction

Maxillary transverse deficiency (MTD) represents one of the most common skeletal discrepancies encountered in orthodontic practice and may affect both growing and adult patients. Clinically, this condition is characterized by an insufficient transverse width of the maxillary basal bone relative to the mandibular arch and is frequently associated with posterior crossbite, dental crowding, palatal constriction, and impaired occlusal relationship [24,39,45,51]. Beyond occlusal alterations, maxillary constriction has also been associated with functional disturbances involving nasal breathing, tongue posture, swallowing patterns, and airway dimensions, potentially influencing craniofacial development and overall quality of life.

The diagnosis of maxillary transverse deficiency may be challenging because compensatory dentoalveolar adaptations can partially mask the underlying skeletal discrepancy. In many patients, the posterior teeth undergo vestibular or lingual inclination to maintain intercuspation, thereby concealing the true extent of the transverse skeletal deficiency [24,26,27,55–56]. Consequently, accurate diagnosis requires a comprehensive clinical and radiographic assessment integrating dental casts or digital models, cephalometric analysis, and three-dimensional imaging modalities such as cone-beam computed tomography (CBCT).

Historically, rapid palatal expansion (RPE) has represented the gold standard for the orthopedic correction of transverse maxillary deficiencies in growing patients. Conventional tooth-borne expanders, including the Haas and Hyrax appliances, apply heavy transverse forces to the posterior dentition to induce separation of the midpalatal suture [37,39,41,45,47–48,51,53]. In pediatric patients, where the suture exhibits limited interdigitation and reduced skeletal resistance, RPE can effectively produce skeletal expansion with acceptable dentoalveolar side effects.

However, the effectiveness of conventional RPE progressively decreases as skeletal maturation increases. During adolescence and adulthood, the midpalatal and circummaxillary sutures undergo increasing interdigitation and partial ossification, substantially increasing resistance to orthopedic expansion [24,26–27,45,55–56]. As a consequence, forces generated by tooth-borne expanders tend to be transmitted predominantly to the dentoalveolar structures rather than to the basal bone, resulting in undesirable side effects such as buccal tipping of posterior teeth, alveolar bone bending, root resorption, gingival recession, and periodontal dehiscence [31,35,37–38,42].

For adult patients presenting advanced sutural maturation, surgically assisted rapid palatal expansion (SARPE) has traditionally been considered the treatment of choice. This technique combines orthopedic expansion with surgical weakening of the maxillary resistance areas, allowing skeletal separation of the palatal suture [8,11,13,31,42–44]. Although SARPE demonstrates high effectiveness in achieving skeletal expansion in adults, it remains an invasive procedure associated with surgical morbidity, increased costs, hospitalization, postoperative discomfort, and potential complications.

The introduction of temporary anchorage devices (TADs) has profoundly modified the biomechanical approach to maxillary expansion. Miniscrew-assisted rapid palatal expansion (MARPE) was developed to overcome the limitations of conventional tooth-borne expanders by transferring expansion forces directly to the palatal skeletal structures through miniscrews inserted into the palatal vault [14,17–18,20,30,49–50,52,54]. Unlike conventional RPE, MARPE reduces the mechanical load applied to the posterior teeth and periodontal tissues, thereby promoting greater skeletal expansion while minimizing dentoalveolar side effects.

Biomechanically, MARPE allows a more favorable distribution of orthopedic forces closer to the center of resistance of the maxillary complex. Bicortical engagement of miniscrews, involving both the palatal cortical bone and the nasal floor cortex, appears to significantly improve appliance stability and facilitate opening of the midpalatal suture even in young adult patients [14,20,30,50,54]. Furthermore, CBCT investigations demonstrated that MARPE may achieve more parallel expansion patterns with reduced buccal tipping compared with conventional RPE [9–10,12,15–16,19,23,28,37–38,46,53].

In recent years, increasing attention has also been directed toward the potential airway and respiratory effects of MARPE. Several studies suggested that skeletal maxillary expansion may increase nasal cavity width and upper airway volume, potentially improving nasal airflow and respiratory function, particularly in patients presenting constricted maxillary arches and mouth-breathing patterns [22,25,29,32–33,35,40,43–44].

Despite the growing popularity of MARPE, the currently available literature remains heterogeneous regarding treatment protocols, appliance designs, patient age, activation schedules, skeletal maturation stages, and evaluated outcomes. Moreover, controversy persists regarding the predictability of skeletal expansion, long-term stability, periodontal effects, and the true indications of MARPE in adult patients.

Therefore, the present systematic review aims to critically evaluate the clinical and biomechanical effectiveness of miniscrew-assisted rapid palatal expansion in the treatment of maxillary transverse deficiency, with particular attention to skeletal expansion, dentoalveolar effects, periodontal outcomes, airway modifications, and treatment success in adolescent and adult patients.

Materials and Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [1].

The objective of the present review was to critically evaluate the current evidence regarding the clinical and biomechanical effects of miniscrew-assisted rapid palatal expansion (MARPE) in the treatment of maxillary transverse deficiency.

PECO Framework

The focused question of the present systematic review was structured according to the PECO framework and formulated as follows: “What are the clinical and biomechanical effects of miniscrew-assisted rapid palatal expansion in patients presenting maxillary transverse deficiency?”

The population considered in this review included adolescent and adult patients diagnosed with maxillary transverse deficiency. The exposure of interest consisted of treatment with miniscrew-assisted rapid palatal expansion appliances, including MARPE and MSE systems. Comparisons included conventional rapid palatal expansion, surgically assisted rapid palatal expansion, alternative expansion protocols, or baseline pre-treatment conditions when a control group was not available. The evaluated outcomes included skeletal expansion, dentoalveolar effects, periodontal changes, airway modifications, treatment success rate, treatment-related complications, and patient-reported outcomes.

Eligibility Criteria

Eligibility criteria were established before the literature search began. Human clinical studies investigating the effects of miniscrew-assisted rapid palatal expansion (MARPE/MSE) in patients presenting maxillary transverse deficiency were considered eligible for inclusion.

Only studies published in the English language between January 2021 and February 2026 were included. Randomized clinical trials, prospective studies, retrospective studies, cohort studies, and controlled clinical investigations evaluating the clinical and biomechanical effects of MARPE were considered eligible.

Studies were included when they assessed at least one clinically relevant outcome related to skeletal expansion, dentoalveolar effects, periodontal outcomes, airway modifications, treatment success, treatment-related complications, or patient-reported outcomes.

Case reports, narrative reviews, systematic reviews, editorials, conference abstracts, letters to the editor, animal studies, cadaveric investigations, and in vitro studies were excluded. Studies exclusively evaluating conventional tooth-borne expanders without skeletal anchorage were also excluded. Duplicate publications and studies lacking clearly reported outcome measurements were not considered eligible for inclusion.

Search Strategy

A systematic electronic search was performed in the PubMed/MEDLINE database. The search was independently conducted by two reviewers and included studies published up to February 2026.

The search strategy combined Medical Subject Headings (MeSH) terms and free-text keywords related to skeletal maxillary expansion and temporary anchorage devices. The following search strategy was applied:

(“MARPE” OR “MSE” OR “miniscrew assisted rapid palatal expansion” OR “skeletal expander” OR “bone borne expansion”) AND (“maxillary transverse deficiency” OR “maxillary constriction” OR “rapid palatal expansion”)

Additionally, a manual screening of the reference lists of the included studies and relevant reviews was performed to identify potentially eligible studies not retrieved through the electronic database search.

Study selection

All records identified through the electronic search were screened according to the PRISMA 2020 flow process. The search performed in PubMed/MEDLINE identified 54 records. After title and abstract screening, 37 records that did not meet the predefined eligibility criteria were excluded. In particular, articles were excluded when they were case reports, in vitro studies, finite element analyses, investigations involving patients younger than 16 years of age, studies evaluating surgically assisted expansion, or studies not specifically related to miniscrew-assisted palatal expansion.

The full texts of 17 potentially eligible articles were subsequently retrieved and assessed in detail. During full-text evaluation, 6 additional studies were excluded because they did not provide quantitative data on the outcomes of interest or because their study designs were not consistent with the aims of the review. At the end of the selection process, 11 studies fulfilled all eligibility criteria and were included in the qualitative synthesis. The study selection process was summarized using a PRISMA flow diagram.

Risk of Bias Assessment

The risk of bias of the included studies was assessed according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions [2]. Randomized controlled trials were evaluated using the Risk of Bias 2.0 tool, whereas non-randomized studies were assessed using the ROBINS-I tool [3]. The assessment was independently performed by two reviewers (A.V. and C.T.T.). The judgments were compared, and any disagreement that could not be resolved through discussion was referred to a third reviewer (M.S.) for final decision.

For randomized studies, the assessment considered the main domains related to the randomization process, deviations from intended interventions, missing outcome data, outcome measurement, and the selection of reported results. Each domain was classified as low risk of bias, some concerns, or high risk of bias, and an overall judgment was assigned accordingly.

For non-randomized studies, the ROBINS-I assessment considered pre-intervention, intervention-related, and post-intervention sources of bias. Specifically, the evaluation included potential confounding, participant selection, classification of the intervention, deviations from the intended intervention, missing data, outcome measurement, and selection of the reported results. Each study was classified as having low, moderate, serious, or critical risk of bias, or as presenting no information when judgment was not possible.

Results

Study Selection

The electronic literature search in the PubMed/MEDLINE database identified 54 records published between January 2021 and February 2026. After the initial screening of titles and abstracts, 37 records that did not meet the predefined eligibility criteria were excluded. The principal reasons for exclusion included in vitro investigations, finite element analyses, case reports, studies involving patients younger than 16 years of age, investigations evaluating surgically assisted rapid palatal expansion, and studies not specifically focused on miniscrew-assisted rapid palatal expansion.

Following the first screening phase, 17 full-text articles were retrieved and assessed for eligibility. During the full-text evaluation, 6 additional studies were excluded due to inappropriate study design, the absence of relevant quantitative outcomes, or inconsistency with the objectives of the review. Ultimately, 11 studies fulfilled all eligibility criteria and were included in the qualitative synthesis. The entire selection process was summarized using a PRISMA 2020 flow diagram (Figure 1).

**Figure 1.** PRISMA 2020 flow diagram of the study selection process.

Characteristics of Included Studies

The studies included in the present review were published between 2022 and 2026 and demonstrated considerable methodological heterogeneity. The selected investigations included randomized controlled trials, prospective clinical studies, retrospective observational studies, and multicenter studies evaluating the clinical and biomechanical effects of MARPE and MSE appliances in adolescent and adult patients with maxillary transverse deficiency [4–7,15–16,25,36,40,57–58].

Sample sizes ranged from approximately 20 to 49 patients, with most studies involving late-adolescent or young-adult populations. Several investigations specifically evaluated patients presenting advanced maturation of the midpalatal suture, reflecting the increasing clinical interest in non-surgical maxillary expansion in skeletally mature individuals.

Different skeletal expansion devices were evaluated across the included studies, including conventional MARPE appliances, MSE-II systems, customized bone-borne expanders, three-dimensional-printed expanders, and hybrid skeletal expanders. Despite differences in appliance design and activation protocols, most studies used cone-beam computed tomography as the principal imaging modality for three-dimensional evaluation of skeletal and dentoalveolar changes.

The evaluated outcomes included skeletal transverse expansion, dentoalveolar effects, periodontal modifications, upper airway changes, treatment success rate, patient-reported discomfort, and midpalatal suture healing after expansion. Follow-up periods varied considerably across studies, ranging from short-term post-expansion evaluations to long-term CBCT analyses conducted up to 12 months after treatment (Table 1).

Table 1. Characteristics of the included studies.

Authors (Year)	Study design	Sample size	Mean age / population	Appliance type	Main outcomes evaluated	Principal findings
Brunetto et al. (2022)	Prospective controlled trial	20 patients	Adults with OSA and transverse deficiency	MARPE	Airway changes; sleep parameters	Improvement in respiratory and sleep-related parameters after skeletal expansion.
Almaqrami et al. (2022)	Prospective clinical study	32 patients	Young adults	Customized MARPE	Skeletal and dentoalveolar expansion assessed	Significant basal skeletal expansion with reduced dentoalveolar side effects.
Sader et al. (2024)	Retrospective observational study	27 patients	Adolescents and young adults	Customized MARPE	Skeletal changes; dental inclination; alveolar effects	Significant transverse skeletal increase associated with mild dentoalveolar tipping.
Anéris et al. (2023)	Prospective clinical study	24 patients	Adults with advanced sutural maturation	MSE	Airway volume and skeletal expansion	Upper airway volumetric increase independent of sutural maturation stage.
Elshehaby et al. (2024)	Randomized controlled trial	48 patients	Non-growing patients	MARPE with/without micro-osteoperforation	Pain perception and airway outcomes	Micro-osteoperforation reduced pain intensity without additional airway benefit.
Zhong and Wang (2024)	Retrospective clinical trial	30 patients	Adults	C-expander MARPE	Periodontal outcomes and skeletal expansion	Skeletal expansion without clinically relevant periodontal dehiscence.
Sharma et al. (2025)	Retrospective multicenter study	42 patients	Late adolescents and adults	Conventional MSE-II vs custom 3D-printed MARPE	Skeletal and dentoalveolar outcomes	Custom 3D-printed MARPE showed greater skeletal expansion in selected patients.
Thi Hong Thuy et al. (2025a)	Prospective study	36 patients	Late adolescents and young adults	Custom Hyrax-type MARPE	Clinical and CBCT outcomes	Substantial skeletal expansion with controlled dental side effects.
Thi Hong Thuy et al. (2025b)	Retrospective observational study	40 patients	Nongrowing patients	Customized MARPE	Sutural healing and bone regeneration	Progressive bone regeneration with complete healing reported by 12 months.
Aras et al. (2026)	Randomized clinical trial	30 patients	Late adolescents and young adults	MARPE vs conventional RPE	Skeletal expansion and nasal permeability	MARPE demonstrated improved nasal permeability and higher skeletal effects.
Allam et al. (2025)	Randomized controlled clinical trial	29 patients	Young adults	Alternate expansion/ constriction protocol with MARPE	Sutural and dentoskeletal effects	Clinical trial included for comparative expansion protocol assessment.

Abbreviations: OSA, obstructive sleep apnea; MARPE, miniscrew-assisted rapid palatal expansion; MSE, micro-implant-supported skeletal expander; CBCT, cone-beam computed tomography; RPE, rapid palatal

Risk of Bias

The methodological quality of the included studies was assessed using the RoB 2.0 tool for randomized clinical trials (Table 2; Figure 2) and the ROBINS-I tool for non-randomized studies (Table 3; Figure 3). Overall, the currently available evidence demonstrates heterogeneous methodological quality, with most observational studies presenting a moderate to serious risk of bias.

Although randomized clinical trials generally demonstrated improved methodological quality, some domains still presented relevant concerns. In particular, blinding of participants and clinicians was not feasible because of the nature of the orthodontic intervention. Moreover, in certain studies, radiographic and clinical outcome measurements were performed by non-blinded assessors, potentially increasing the risk of measurement bias.

Overall, the certainty of evidence ranged from low to moderate, emphasizing the need for additional high-quality prospective and randomized clinical studies with standardized protocols and long-term follow-up.

Table 2. Risk-of-bias assessment of randomized controlled trials using the RoB 2 tool.

Domains
Study:	Bias arising from the randomisation process:	Bias arising from deviations from planned actions:	Bias due to missing outcome data:	Bias in the measurement of missing outcomes:	Bias in the selection of the data presented:	Overall assessment of the risk of bias:
Elshehaby et al., 2024	LOW RISK OF BIAS	SOME CONCERNS	SOME CONCERNS	LOW RISK OF BIAS	LOW RISK OF BIAS	SOME CONCERNS
Allam et al., 2025	SOME CONCERNS	SOME CONCERNS	HIGH RISK OF BIAS	SOME CONCERNS	LOW RISK OF BIAS	HIGH RISK OF BIAS
Aras et al., 2026	LOW RISK OF BIAS	SOME CONCERNS	LOW RISK OF BIAS	SOME CONCERNS	SOME CONCERNS	SOME CONCERNS

**Figure 2.** Traffic-light summary of risk-of-bias judgments for randomized controlled trials
Summary of risk of bias: the review authors’ assessment of each RoB 2 domain in randomized controlled trials. Key: green circle = low risk of bias; yellow circle = some concerns; red circle = high risk of bias. Domains: D1 = bias arising from the randomization process; D2 = bias due to deviations from intended interventions; D3 = bias due to missing outcome data; D4 = bias in measurement of the outcome; D5 = bias in selection of the reported result; Total = overall risk.

Table 3. Risk-of-bias assessment of non-randomized studies using the ROBINS-I tool.

Domains
Study	Pre-intervention		Intervention	Post-intervention				Total
Study	Bias due to confounding factors:	Bias in the selection of participants:	Bias in the classification of exposures/interventions:	Bias arising from deviations from planned interventions:	Biases caused by missing data:	Bias in the measurement of outcomes:	Bias in the selection of the reported result:
Brunetto et al., 2022	HIGH RISK OF BIAS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	SOME CONCERNS	SOME CONCERNS	HIGH RISK OF BIAS
Aneris et al.,2023	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS
Almaqrami et al., 2022	HIGH RISK OF BIAS	HIGH RISK OF BIAS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	HIGH RISK OF BIAS
Braga Sader et al., 2023	HIGH RISK OF BIAS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	HIGH RISK OF BIAS
Zhong et al., 2024	HIGH RISK OF BIAS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	HIGH RISK OF BIAS
Sharma et al., 2025	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS
Thuy et al., 2025	HIGH RISK OF BIAS	SOME CONCERNS	LOW RISK	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	HIGH RISK OF BIAS
Thuy et al., 2025	SOME CONCERNS	SOME CONCERNS	LOW RISK	SOME CONCERNS	LOW RISK OF BIAS	LOW RISK	SOME CONCERNS	SOME CONCERNS

**Figure 3.** Traffic-light summary of ROBINS-I risk-of-bias judgments for non-randomized studies.
Summary of risk of bias: the review authors’ assessment of each ROBINS-I domain in non-randomized studies. Key: green circle = low risk of bias; yellow circle = some concerns/moderate risk; red circle = high/serious risk of bias. Domains: D1 = bias due to confounding; D2 = bias in selection of participants; D3 = bias in classification of interventions; D4 = bias due to deviations from intended interventions; D5 = bias due to missing data; D6 = bias in measurement of outcomes; D7 = bias in selection of the reported result; Total = overall risk.

Main Findings

Skeletal Expansion and Treatment Success

Most of the included studies reported successful opening of the midpalatal suture following MARPE treatment, even in late adolescent and adult patients presenting advanced skeletal maturation. Reported treatment success rates ranged from approximately 60% to 85%, confirming the ability of miniscrew-assisted expansion to achieve orthopedic skeletal effects in patients who would traditionally be considered candidates for surgically assisted expansion. CBCT analyses consistently demonstrated significant increases in transverse skeletal dimensions after treatment. Skeletal expansion at the basal bone level ranged from approximately 4 to 5 mm in most studies, while posterior skeletal expansion values frequently corresponded to nearly 80–85% of anterior expansion measurements, suggesting a relatively parallel expansion pattern [4,6–7,15–16,25,36,40,57–58].

Several investigations additionally reported significant increases in nasal cavity width and maxillary transverse dimensions following treatment. Customized skeletal expanders and appliances supported by bicortical miniscrew anchorage appeared to produce greater skeletal effects and improved appliance stability compared with conventional tooth-borne expanders.

Dentoalveolar and Periodontal Effects

Although MARPE was specifically developed to reduce the dentoalveolar side effects associated with conventional rapid palatal expansion, several studies still reported measurable dental tipping and alveolar remodeling after treatment. Buccal inclination of posterior teeth ranged from approximately 3° to 5°, while increases in intermolar and intercanine widths were consistently observed across studies [7,15–16,23,28,36–38,57].

Nevertheless, the magnitude of dentoalveolar compensation generally appeared lower than that historically reported for conventional tooth-borne expanders. CBCT analyses suggested that the incorporation of skeletal anchorage allowed a more favorable distribution of expansion forces to the maxillary basal bone, partially reducing undesirable dental side effects.

Regarding periodontal outcomes, the included studies reported limited periodontal complications after MARPE treatment. Although localized reductions in buccal alveolar bone thickness were observed in some patients, severe periodontal defects such as extensive dehiscences or gingival recessions were uncommon. Some investigations additionally documented compensatory palatal bone apposition during the retention phase, suggesting adaptive periodontal remodeling following expansion [15,37–38,57–58].

Airway Changes and Respiratory Outcomes

Several included studies evaluated the effects of MARPE on upper airway dimensions and respiratory parameters. Significant increases in nasal cavity width and upper airway volume were consistently reported after treatment. Improvements in nasal permeability and respiratory function were also observed, particularly in patients presenting constricted maxillary arches associated with mouth breathing or sleep-related respiratory disturbances [4–5,22,25,29,32–33,35,40].

One study investigating adult patients affected by obstructive sleep apnea reported improvements in home sleep test parameters and patient-reported quality of life after treatment. However, considerable heterogeneity among studies regarding airway assessment methods and follow-up duration limited direct comparison of the reported findings.

Pain Perception and Midpalatal Suture Healing

Pain perception was specifically assessed in the randomized trial evaluating MARPE with and without micro-osteoperforation. The available evidence suggested that micro-osteoperforation may reduce activation-related pain, although it did not provide additional airway benefits [5].

Midpalatal suture healing was evaluated using CBCT follow-up in studies assessing post-expansion bone regeneration. Progressive remineralization of the expanded suture was described during the retention phase, with complete suture healing reported at 12 months in the available observational evidence [58].

Discussion

The present systematic review evaluated the current evidence regarding the clinical and biomechanical effects of miniscrew-assisted rapid palatal expansion in patients presenting maxillary transverse deficiency. Overall, the included studies demonstrated that MARPE is capable of producing significant skeletal expansion even in late adolescent and adult patients, reducing the need for surgically assisted expansion in selected cases.[4–7,15–16,25,36,40,57–58] In addition, the available evidence suggested that skeletal anchorage may reduce the dentoalveolar side effects typically associated with conventional rapid palatal expansion, although these effects are not completely eliminated.

One of the principal findings emerging from the present review concerns the ability of MARPE to achieve clinically significant orthopedic expansion in skeletally mature patients. Traditionally, conventional rapid palatal expansion has been considered effective mainly in growing patients because of the progressive interdigitation and ossification of the midpalatal suture occurring with skeletal maturation [24,26–27,45,55–56]. In adult individuals, the increased resistance of the circummaxillary sutural system tends to limit skeletal expansion and favor dentoalveolar compensation. The introduction of skeletal anchorage systems has substantially modified this biomechanical scenario by allowing expansion forces to be transferred more directly to the maxillary basal bone.

From a biomechanical perspective, the incorporation of palatal miniscrews appears to improve orthopedic force distribution and reduce the concentration of forces on the posterior dentition and periodontal structures. Bicortical engagement of miniscrews, involving both the palatal cortical plate and the nasal floor cortex, has been proposed as a key factor contributing to appliance stability and successful sutural opening in adult patients [14,20,30,50,54]. The studies included in the present review consistently reported substantial skeletal expansion at the level of the maxillary basal bone and nasal cavity, supporting the hypothesis that MARPE may generate a more parallel expansion pattern compared with conventional tooth-borne expanders.

Nevertheless, despite the predominantly skeletal nature of MARPE expansion, dentoalveolar side effects were still observed in most investigations. Buccal tipping of posterior teeth, alveolar bone remodeling, and changes in dental inclination remained present after treatment, although their magnitude generally appeared lower than that historically associated with conventional rapid palatal expansion. These findings are consistent with previous CBCT investigations demonstrating that no currently available expansion protocol is capable of producing purely skeletal expansion without some degree of dentoalveolar adaptation [7,15–16,23,28,36–38,57].

The periodontal implications of skeletal expansion also deserve particular attention. Several studies included in the present review reported localized reductions in buccal alveolar bone thickness after treatment, especially at the level of posterior teeth. However, severe periodontal complications such as extensive dehiscences, gingival recession, or major attachment loss were relatively uncommon. Interestingly, some investigations documented compensatory palatal bone apposition during the retention phase, suggesting the presence of adaptive periodontal remodeling after expansion [15,37,38,57–58]. These findings support the importance of careful pre-treatment CBCT evaluation of alveolar morphology and periodontal phenotype, particularly in adult patients presenting thin cortical plates or pre-existing periodontal vulnerability.

Another clinically relevant aspect emerging from the current literature concerns the possible effects of MARPE on upper airway dimensions and respiratory function [4–5,22,25,29,32–33,35,40]. Several included studies reported significant increases in nasal cavity width and upper airway volume after treatment, potentially reflecting the close anatomic relationship between the maxillary complex and the nasal airway. Improvements in nasal permeability and respiratory parameters were also observed in some patient populations, including individuals presenting obstructive sleep-related symptoms. Nevertheless, the currently available evidence remains heterogeneous regarding imaging protocols, airway assessment methods, and follow-up duration. Consequently, although MARPE may potentially contribute to improvement of respiratory function in selected patients, additional well-designed prospective studies are still necessary before definitive clinical conclusions can be established.

An additional important finding concerns biologic healing of the midpalatal suture following expansion. CBCT-based studies evaluating sutural bone regeneration demonstrated progressive remineralization of the expanded suture during the retention phase, with substantial recovery of bone density observed within approximately 12 months after treatment. These findings may have important implications for post-expansion retention protocols and long-term skeletal stability.

Despite the promising clinical outcomes reported in the current literature, several important methodological limitations must be considered. Most included investigations were retrospective observational studies characterized by relatively small sample sizes, heterogeneous patient populations, and limited follow-up periods. Considerable variability was also observed regarding appliance design, number and position of miniscrews, activation protocols, retention duration, and evaluated outcomes. Furthermore, only a limited number of randomized controlled trials are currently available, reducing the overall certainty of evidence [2–3,17,21,34,39,45,48].

Another important limitation concerns the heterogeneity of radiographic assessment protocols. Although most recent investigations employed CBCT imaging, differences in landmark identification, measurement protocols, and superimposition techniques complicate direct comparison among studies. Similarly, variability in skeletal maturation assessment may partially influence the interpretation of treatment success rates in adult patients.

From a clinical perspective, the currently available evidence suggests that MARPE may represent a valid alternative to surgically assisted rapid palatal expansion in selected late adolescent and adult patients presenting moderate maxillary transverse deficiency. However, accurate diagnosis, careful patient selection, individualized biomechanical planning, and appropriate assessment of skeletal maturation remain essential to optimize treatment predictability and minimize complications. Particular attention should be directed toward bicortical miniscrew stability, periodontal phenotype, and retention management.

Further high-quality prospective studies and randomized clinical trials with standardized protocols, larger sample sizes, and long-term follow-up are required to better clarify the true orthopedic potential, long-term stability, periodontal implications, and airway effects of miniscrew-assisted rapid palatal expansion.

Conclusions

Within the limitations of the currently available evidence, miniscrew-assisted rapid palatal expansion appears to represent an effective treatment modality for the management of maxillary transverse deficiency in late adolescent and adult patients. The incorporation of skeletal anchorage through palatal miniscrews allows clinically significant transverse skeletal expansion while reducing, although not completely eliminating, the dentoalveolar side effects commonly associated with conventional tooth-borne rapid palatal expansion.

The reviewed studies demonstrated that MARPE is capable of achieving successful midpalatal suture opening and substantial skeletal expansion even in patients presenting advanced skeletal maturation. In addition, CBCT-based investigations suggested favorable effects on nasal cavity dimensions and upper airway morphology, together with acceptable periodontal adaptation and progressive biologic healing of the expanded suture during the retention phase.

Despite these promising findings, important limitations remain regarding the quality and heterogeneity of the currently available evidence. Most studies included in the present review were observational investigations characterized by relatively small sample sizes, heterogeneous treatment protocols, and limited follow-up periods. Consequently, the long-term stability, periodontal implications, and true orthopedic predictability of MARPE still require further investigation.

Careful patient selection, individualized biomechanical planning, adequate evaluation of skeletal maturation, and precise control of miniscrew positioning remain essential to optimize clinical outcomes and minimize treatment-related complications.

Further high-quality prospective studies and randomized clinical trials with standardized protocols and long-term follow-up are necessary to better define the clinical indications, biomechanical characteristics, and long-term effectiveness of miniscrew-assisted rapid palatal expansion.

Funding

The authors declare that no funding was received.

Conflicts of Interest

The authors declare no conflict of interest

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