BackgroundMini-implant-assisted rapid palatal expansion (MARPE) appliances have been developed with the aim to enhance the orthopedic effect induced by rapid maxillary expansion (RME). Maxillary Skeletal Expander (MSE) is a particular type of MARPE appliance characterized by the presence of four mini-implants positioned in the posterior part of the palate with bi-cortical engagement. The aim of the present study is to evaluate the MSE effects on the midpalatal and pterygopalatine sutures in late adolescents, using high-resolution CBCT. Specific aims are to define the magnitude and sagittal parallelism of midpalatal suture opening, to measure the extent of transverse asymmetry of split, and to illustrate the possibility of splitting the pterygopalatine suture.MethodsFifteen subjects (mean age of 17.2 years; range, 13.9–26.2 years) were treated with MSE. Pre- and post-treatment CBCT exams were taken and superimposed. A novel methodology based on three new reference planes was utilized to analyze the sutural changes. Parameters were compared from pre- to post-treatment and between genders non-parametrically using the Wilcoxon sign rank test. For the frequency of openings in the lower part of the pterygopalatine suture, the Fisher’s exact test was used.ResultsRegarding the magnitude of midpalatal suture opening, the split at anterior nasal spine (ANS) and at posterior nasal spine (PNS) was 4.8 and 4.3 mm, respectively. The amount of split at PNS was 90% of that at ANS, showing that the opening of the midpalatal suture was almost perfectly parallel antero-posteriorly. On average, one half of the anterior nasal spine (ANS) moved more than the contralateral one by 1.1 mm. Openings between the lateral and medial plates of the pterygoid process were detectable in 53% of the sutures (P < 0.05). No significant differences were found in the magnitude and frequency of suture opening between males and females. Correlation between age and suture opening was negligible (R 2 range, 0.3–4.2%).ConclusionsMidpalatal suture was successfully split by MSE in late adolescents, and the opening was almost perfectly parallel in a sagittal direction. Regarding the extent of transverse asymmetry of the split, on average one half of ANS moved more than the contralateral one by 1.1 mm. Pterygopalatine suture was split in its lower region by MSE, as the pyramidal process was pulled out from the pterygoid process. Patient gender and age had a negligible influence on suture opening for the age group considered in the study.

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Introduction: Miniscrew-assisted rapid palatal expansion (MARPE) appliances utilize the skeletal anchorage to expand the maxilla. One type of MARPE device is the Maxillary Skeletal Expander (MSE), which presents four micro-implants with bicortical engagement of the palatal vault and nasal floor. MSE positioning is traditionally planned using dental stone models and 2D headfilms. This approach presents some critical issues, such as the inability to identify the MSE position relative to skeletal structures, and the potential risk of damaging anatomical structures. Methods: A novel methodology has been developed to plan MSE position using the digital model of dental arches and cone-beam computed tomography (CBCT). A virtual model of MSE appliance with the four micro-implants was created. After virtual planning, a positioning guide is virtually designed, 3D printed, and utilized to model and weld the MSE supporting arms to the molar bands. The expansion device is then cemented in the patient oral cavity and micro-implants inserted. A clinical case of a 12.9-year-old female patient presenting a Class III malocclusion with transverse and sagittal maxillary deficiency is reported. Results: The midpalatal suture was opened with a split of 3.06 mm and 2.8 mm at the anterior and posterior nasal spine, respectively. After facemask therapy, the sagittal skeletal relationship was improved, as shown by the increase in ANB, A-Na perpendicular and Wits cephalometric parameters, and the mandibular plane rotated 1.6°clockwise. Conclusion: The proposed digital methodology represents an advancement in the planning of MSE positioning, compared to the traditional approach. By evaluating the bone morphology of the palate and midface on patient CBCT, the placement of MSE is improved regarding the biomechanics of maxillary expansion and the bone thickness at micro-implants insertion sites. In the present case report, the digital planning was associated with a positive outcome of maxillary expansion and protraction in safety conditions.

Background and objectives Micro-implant-assisted expanders have shown significant effects on the mid-face, including a degree of asymmetry. The aim of this study is to quantify the magnitude, parallelism, and asymmetry of this type of expansion in non-growing patients. Methods A retrospective study on a sample of 31 non-growing patients with an average age of 20.4 years old, with cone beam computed tomography images taken before and right after expansion using maxillary skeletal expander (MSE) were assessed for skeletal expansion at three landmarks bilaterally. Results Average magnitude of total expansion was 4.98 mm at the anterior nasal spine (ANS) and 4.77 mm at the posterior nasal spine (PNS) which showed statistical significance using a paired t test with p < 0.01. Average expansion at the PNS was 95% of that at the ANS. The sample was divided into symmetric (n = 15) and asymmetric (n = 16) based on the difference in expansion at the ANS, with 16 out of 31 patients exhibiting statistically significant asymmetry. Conclusions MSE achieves distinctly parallel expansion in the sagittal plane but can exhibit asymmetrical expansion in the transverse plane.

BackgroundMiniscrew-assisted rapid palatal expansion (MARPE) has been adopted in recent years to expand the maxilla in late adolescence and adult patients. Maxillary Skeletal Expander (MSE) is a device that exploits the principles of skeletal anchorage to transmit the expansion force directly to the maxillary bony structures and is characterized by the miniscrews’ engagement of the palatal and nasal cortical bone layers. In the literature, it has been reported that the zygomatic buttress is a major constraint that hampers the lateral movement of maxilla, since maxilla is located medially to the zygomatic arches. The objective of the present study is to analyze the changes in the zygomatic bone, maxillary bone, and zygomatic arches and to localize the center of rotation for the zygomaticomaxillary complex in the horizontal plane after treatment with MSE, using high-resolution cone-beam computed tomography (CBCT) images.MethodsFifteen subjects with a mean age of 17.2 (± 4.2) years were treated with MSE. CBCT records were taken before and after miniscrew-assisted maxillary expansion; three linear and four angular parameters were identified in the axial zygomatic section (AZS) and were compared from pre-treatment to post-treatment using the Wilcoxon signed rank test.ResultsAnterior inter-maxillary distance increased by 2.8 mm, posterior inter-zygomatic distance by 2.4 mm, angle of the zygomatic process of the temporal bone by 1.7° and 2.1° (right and left side) (P < 0.01). Changes in posterior inter-temporal distance and zygomaticotemporal angle were negligible (P > 0.05).ConclusionsIn the horizontal plane, the maxillary and zygomatic bones and the whole zygomatic arch were significantly displaced in a lateral direction after treatment with MSE. The center of rotation for the zygomaticomaxillary complex was located near the proximal portion of the zygomatic process of the temporal bone, more posteriorly and more laterally than what has been reported in the literature for tooth-borne expanders. Bone bending takes place in the zygomatic process of the temporal bone during miniscrew-supported maxillary expansion.

The miniscrew-assisted rapid palatal expansion approach has given new opportunities for the treatment of maxilla transverse deficiency by providing an alternative to the surgical approach for adult patients. However, the presence of a thin palatal bone can compromise the success of such approach. Recently, the digital planning of the miniscrew-assisted appliances has offered unique advantages in terms of safety and accuracy of the overall process. The aim of this study is to describe the digital planning and MSE fabrication with cad-cam technology using 6 mini-screws in cases with a palatal bone thickness of less than 2.5 mm.

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The introduction of digital workflows and their combination with miniscrew assisted appliances has opened new and enthusiastic perspectives in modern orthodontics. However, in all digital workflows currently in use for orthodontic tooth movement, the miniscrews are inserted first in the maxillary bone, often by means of a surgical guide, and then the appliance is fabricated and secured over the miniscrews with different fixation mechanisms. By doing so, some adaptation problems can be encountered while securing the appliance over the miniscrews, and the chairside time required can therefore be significant. In the present study, we introduce a digital workflow for the design and fabrication of a new appliance, customized on the individual morphology of maxillary bone by using patient Cone Beam Computed Tomography CBCT, for sagittal and vertical orthodontic tooth movement (DIVA, divergent anchors). Differently from the existing protocols, the appliance is cemented first intraorally, serving as a surgical guide for the subsequent insertion of miniscrews. In this way, the adaptation problems are avoided and the chair-side time is reduced.