Original Article

Skeletal and dentoalveolar effects of slow vs rapid activation protocols of

miniscrew-supported maxillary expanders in adolescents:
A randomized clinical trial
Yomna M. Yacouta; Essam M. Abdallab; Nadia M. El Harounyb

ABSTRACT
Objectives: To compare between skeletal and dentoalveolar effects of slow and rapid activation of
miniscrew-supported expanders.
Materials and Methods: A total of 30 patients were randomly allocated to two groups using block
randomization and the allocation ratio 1:1. Both groups received maxillary expanders anchored
using four miniscrews. Activation protocol was once every other day in the slow expansion (SME)
group and twice daily in the rapid expansion (RME) group. Cone-beam computed tomography
(CBCT) scans were obtained before expansion and after removal of the expanders. Transverse
skeletal and dentoalveolar changes were measured using CBCT.
Results: A total of 12 patients in the SME group (mean age, 14.30 6 1.37 years) and 12 patients in
the RME group (mean age, 15.07 6 1.59 years) were analyzed. RME showed significantly greater
widening of the mid-palatal suture at the level of first molars (mean difference [SME  RME] ¼0.61
mm), and a greater increase in right and left molar buccal inclination (mean difference= 3.838 and
2.038, respectively). Percentage of skeletal expansion relative to the jackscrew opening was not
significantly different between the groups. Palatal inflammation was evident following appliance
removal. Miniscrew mobility and bending were observed with RME.
Conclusions: Both SME and RME were effective in correcting skeletal transverse maxillary
deficiency. However, RME resulted in more buccal tipping of maxillary molars and in miniscrew
failures and bending. (Angle Orthod. 2022;92:579–588.)
KEY WORDS: Rapid maxillary expansion; Slow maxillary expansion; Miniscrew-supported
expansion; Activation protocol

INTRODUCTION often results in adverse effects, including buccal tipping

and root resorption of anchor teeth, gingival recession,
Transverse maxillary deficiency is commonly en- and fenestration of the buccal bone.2–4
countered by orthodontists, and its treatment usually Miniscrew-supported maxillary expanders were pro-
involves rapid maxillary expansion (RME).1 Many posed to reduce the deleterious effects of conventional
tooth-supported expanders were described in the expanders.5 The effectiveness of maxillary expanders
literature, but their expansion forces are transmitted supported solely by miniscrews without banding any
to the mid-palatal suture through anchor teeth, which teeth was previously demonstrated using cone-beam
computed tomography (CBCT).5–11
Tooth-supported expanders are commonly activated
a
Lecturer, Department of Orthodontics, Faculty of Dentistry,
Alexandria University, Alexandria, Egypt. rapidly to maximize skeletal effects and minimize
b
Professor, Department of Orthodontics, Faculty of Dentistry, dentoalveolar effects.12 However, it is currently not
Alexandria University, Alexandria, Egypt. clear whether this activation protocol may be appro-
Corresponding author: Yomna M. Yacout, Department of priate to miniscrew-supported expanders. A recent
Orthodontics, Faculty of Dentistry, Alexandria University, Cham-
finite element analysis study found that a single
pollion St, Azarita, Alexandria 21521, Egypt
(e-mail: [email protected]) miniscrew-supported expander activation resulted in
the same amount of mid-palatal suture opening as
Accepted: May 2022. Submitted: November 2021.
Published Online: June 30, 2022 three activations of tooth-supported expanders.13
Ó 2022 by The EH Angle Education and Research Foundation, Hence, it was suggested that the activation protocol
Inc. should be slow to allow dissipation of stresses to avoid

DOI: 10.2319/112121-856.1 579 Angle Orthodontist, Vol 92, No 5, 2022

580 YACOUT, ABDALLA, EL HAROUNY

bone fractures around miniscrews that in turn might mean difference for comparison between the two
affect miniscrew stability.13 groups using independent-samples t-tests, and the
Activation protocols of miniscrew-supported expand- standard deviation (SD) of suture separation was set
ers in previous studies ranged from slow expansion at 1.5.9 At a ¼ 0.05 and a power of 0.90, a minimum
once every other day5 to rapid expansion four times sample size of 12 patients per group was required,
daily.10 The most common expansion regimen, howev- which was increased to 15 patients to allow for
er, was found to be twice daily.7,9,11,14 A recent possible attrition.
systematic review found that a comparison between
miniscrew-supported slow maxillary expansion (SME) Randomization
and RME has not been described in the literature.15
Therefore, this randomized clinical trial (RCT) was Patients were randomly assigned to one of two
conducted to evaluate and compare between skeletal groups (SME or RME) via computer-generated block
and dentoalveolar effects of slow and rapid activation randomization with a block size of six and a 1:1
protocols of miniscrew-supported maxillary expanders. allocation ratio.17 Allocation was concealed from the
The null hypothesis was that there would be no orthodontist and the patients using sequentially
difference between the activation protocols regarding numbered, opaque, sealed envelopes prepared by
their skeletal and dentoalveolar effects on the maxilla. another researcher. When deemed eligible, each
patient’s name was written on the next envelope in
MATERIALS AND METHODS the sequence, the envelope was then opened, and
the group allocation was reported to the orthodon-
Trial Design tist.
This study was a single-center, two-arm parallel RCT
with a 1:1 allocation ratio. The protocol was registered Interventions
at Clinicaltrials.gov (NCT04225637). Oral assents and informed consents were obtained
from patients and parents, respectively, before study
Participants, Eligibility Criteria, and Setting commencement. Both groups received a miniscrew-
Patients were recruited from the outpatient clinic, supported maxillary expander (Figure 1). Four self-
Faculty of Dentistry, Alexandria University after drilling miniscrews (1.6 3 10 mm, H-screw, Hubit Co
obtaining approval from the faculty’s research ethics Ltd, Ojeon-Dong, Korea) were placed in the palate,
committee (IRB: 00010556 - IORG: 0008839). Inclu- bilaterally, between the first and second premolars and
sion criteria were age 12–16 years, permanent between the second premolars and first molars. An
dentition, good oral hygiene, and transverse maxillary alginate impression was made and poured in dental
deficiency warranting skeletal maxillary expansion. stone. A 9-mm expansion screw (Leone Orthodontic
The need was quantified on digital dental casts by Products, Sesto Fiorentino, Firenze, Italy) was placed,
measuring the difference between maxillary width and acrylic pads were fabricated. The finished appli-
(distance between right and left most concave points ance was cemented using light-cure flowable compos-
of the maxillary vestibule at the mesio-buccal cusp of ite resin (Te-econom flow, Ivoclar Vivadent, Schaan,
the first molars) and mandibular width (distance Liechtenstein). The appliance was activated once
between right and left mandibular WALA ridge at the every other day in SME group and twice daily in
mesio-buccal groove of the first molars).16 Patients RME group. Expansion was considered complete
with a history of maxillary trauma, previous orthodon- when transverse maxillary deficiency was corrected
tic treatment, congenital craniofacial malformations, as measured on digital dental casts.18 The appliance
or systemic diseases or who were taking medications was left in place for retention. At the end of the
were excluded. Participants were excluded in cases retention period, 5 months after the initial activation,
of oral hygiene deterioration, lack of miniscrew the appliance was removed.
primary stability, failure of all miniscrews during the CBCT scans were obtained before expansion (T1)
experimental period, or discontinuation requests as a and after removal of the appliance (T2) with the
result of severe pain. following parameters: 120 Kvp, 5 mA, 640 3 640 3
544 field of view, 25-second scanning time, and 0.25
Sample Size Calculation voxel size (i-CAT Next Generation, Imaging Sciences
Sample size calculation was made using NCSS International, Hatfield, Pa). Data were exported in
2004 and PASS 2000 programs (NCSS LLC, Kays- Digital Imaging and Communications in Medicine
ville, Utah). A mean difference of sutural separation at (DICOM) format and processed using OnDemand3D
the maxillary first molars of 2 mm was used as the software (Cybermed Inc., Seoul, Korea). To standard-

Angle Orthodontist, Vol 92, No 5, 2022

SLOW VS RAPID MINISCREW-SUPPORTED EXPANSION 581

Figure 1. Pre- and postexpansion occlusal photographs of (A and A’) an SME patient and (B and B’) an RME patient.

ize the analysis procedures, the axial plane was Outcomes

reoriented to be parallel to the palatal plane in both
Primary outcomes of the study were the transverse
the sagittal and coronal cuts. Then, the coronal axis skeletal and dentoalveolar changes at the end of the
was reoriented in the axial cut to bisect the palatal retention period measured using CBCT. The measured
roots of maxillary first premolars or first molars when parameters are defined in Table 1 and shown in
making measurements at the level of first premolars or Figures 2 and 3. Secondary patient-related outcomes
at the level of first molars, respectively. will be reported in a future publication.

Figure 2. Skeletal transverse measurements. (A) At first premolars. (B) At first molars. (See Table 1 for abbreviations.)

Angle Orthodontist, Vol 92, No 5, 2022

582 YACOUT, ABDALLA, EL HAROUNY

Table 1. Definitions of Measured Parameters on the CBCT

Parameter Definition
Skeletal parameters
SWN-4 Suture width at nasal floor at Widest intermaxillary suture width between the right and left cortical borders at the
first premolar nasal floor measured on the coronal slice at the level of maxillary first premolars
SWP-4 Suture width at palatal floor at Widest intermaxillary suture width between the right and left cortical borders at the
first premolar palatal floor measured on the coronal slice at the level of maxillary first premolars
SW-4 Average suture width at first The average suture width on the coronal slice at the first premolar calculated as the
premolar average of SWN-4 and SWP-4
SWN-6 Suture width at nasal floor at first Widest intermaxillary suture width between the right and left cortical borders at the
molar nasal floor measured on the coronal slice at the level of maxillary first molars
SWP-6 Suture width at palatal floor at Widest intermaxillary suture width between the right and left cortical borders at the
first molar palatal floor measured on the coronal slice at the level of maxillary first molars
SW-6 Average suture width at first molar The average suture width on the coronal slice at the first molar calculated as the
average of SWN-6 and SWP-6
BBW-4 Basal bone width at first premolar Maxillary basal bone width measured on the coronal slice at the level of the maxillary
first premolars on a line parallel to the palatal plane and tangent to the lower border
of the hard palate
BBW-6 Basal bone width at first molar Maxillary basal bone width measured on the coronal slice at the level of the maxillary
first molars on a line parallel to the palatal plane and tangent to the lower border of
the hard palate
ABW-4 Alveolar bone width at first Widest maxillary alveolar bone width measured on the coronal slice at the level of the
premolar maxillary first premolars
ABW-6 Alveolar bone width at first molar Widest maxillary alveolar bone width measured on the coronal slice at the level of the
maxillary first molars
Dentoalveolar parameters
Apex-4 First premolar interapex width Distance between the (palatal) root apex of the maxillary right first premolar and
maxillary left first premolar
Apex-6 First molar interapex width Distance between the palatal root apex of the maxillary right first molar and maxillary
left first molar
Cusp-4 First premolar intercusp width Distance between the palatal cusp tip of the maxillary right first premolar and maxillary
left first premolar
Cusp-6 First molar intercusp width Distance between the palatal cusp tip of the maxillary right first molar and maxillary left
first molar
RtDentInc-4 Right first premolar inclination Buccolingual inclination of the maxillary right first premolar measured as the angle
between its (palatal) root axis and a horizontal reference line parallel to the palatal
plane
LtDentInc-4 Left first premolar inclination Buccolingual inclination of the maxillary left first premolar measured as the angle
between its (palatal) root axis and a horizontal reference line parallel to the palatal
plane
RtDentInc-6 Right first molar inclination Buccolingual inclination of the maxillary right first molar measured as the angle
between its palatal root axis and a horizontal reference line parallel to the palatal
plane
LtDentInc-6 Left first molar inclination Buccolingual inclination of the maxillary left first molar measured as the angle between
its palatal root axis and a horizontal reference line parallel to the palatal plane
RtAlvInc-4 Right first premolar alveolar Angle between the palatal alveolar bone of the right maxillary first premolar and a
inclination horizontal reference line parallel to the palatal plane
LtAlvInc-4 Left first premolar alveolar Angle between the palatal alveolar bone of the left maxillary first premolar and a
inclination horizontal reference line parallel to a horizontal reference line parallel to the palatal
plane
RtAlvInc-6 Right first molar alveolar Angle between the palatal alveolar bone of the right maxillary first molar and a
inclination horizontal reference line parallel to the palatal plane
LtAlvInc-6 Left first molar alveolar inclination Angle between the palatal alveolar bone of the left maxillary first molar and a horizontal
reference line parallel to the palatal plane

Blinding Statistical Analysis

Because of the nature of the intervention, blinding of Statistical analysis was performed using IBM SPSS
the patients or the orthodontist was not possible. software, version 25 (IBM Corp., Armonk, N.Y.).
However, the statistician was blinded during data Significance level was set at P  .05. Data were
assessment. tested for normal distribution using descriptive statis-

Angle Orthodontist, Vol 92, No 5, 2022

SLOW VS RAPID MINISCREW-SUPPORTED EXPANSION 583

Figure 3. Dentoalveolar measurements. (A and B) Linear measurements at first premolars and first molars. (C and D) Angular measurements at
first premolars and first molars. (See Table 1 for abbreviations.)

tics, plots (histogram and box plot), and Shapiro-Wilk remaining at the end of the expansion period despite
test. When found to be normally distributed, parametric correcting the skeletal transverse discrepancy.
tests were applied, and when not normally distributed, Intraexaminer and interexaminer reliability for the
nonparametric tests were applied. To calculate the measured CBCT variables were considered excellent
error of measurement, CBCT measurements were (ICC greater than 0.90).19
repeated after 2 weeks by the same researcher and Changes in the measured parameters from T1 to T2
another investigator on 20% of the sample. Intra- in both groups are shown in Table 3. RME resulted in
examiner and interexaminer reliability were assessed significantly greater sutural expansion at the level of
using intraclass correlation coefficient (ICC). first molars compared with SME. The increase in first
molar intercusp width was significantly higher with
RESULTS RME compared with SME, whereas the increase in
interapex width was significantly higher with SME
Patient recruitment started in February 2019 and compared with RME. The increase in first molar dental
ended when the required sample size was attained in inclination was significantly higher in RME than in
December 2020. Flow of participants during the trial SME.
and reasons for losses and exclusions from the study The mean mid-palatal suture expansion at the level
are shown in Figure 4. The demographic and clinical of first molars (SW-6) was 38.99% 6 12.26% and
characteristics of both groups are shown in Table 2. 48.58% 6 13.67% of the jackscrew opening in the
The intervention was discontinued for one RME SME and RME groups, respectively. An independent-
patient because of loosening of all miniscrews during samples t-test did not show any significant difference
appliance activation as evidenced by appliance mobil- between the two groups (P ¼ .084).
ity, enlargement of palatal soft tissues around the The percentage of skeletal expansion (SW-4) out of
appliance, and failure to develop a midline diastema. total expansion (Cusp-4) at the level of first premolars
The posterior crossbite was successfully corrected in was 62.12% 6 16.62% in the SME group and 50.24%
all patients analyzed in the RME group. Conversely, 6 16.86% in the RME group, and an independent-
two patients in the SME group had a dental crossbite samples t-test did not show any significant difference

Angle Orthodontist, Vol 92, No 5, 2022

584 YACOUT, ABDALLA, EL HAROUNY

Figure 4. Consolidated Standards of Reporting Trials flowchart.

between the two groups (P ¼ .096). Similarly, at the Harms

level of first molars, the percentage of skeletal
All patients showed inflammation of the palatal
expansion (SW-6) out of total expansion (Cusp-6) mucosa following appliance removal. Miniscrew mobil-
was not significantly different (P ¼ .273) between the ity was observed at the time of appliance removal in
two groups (47.35% 6 17.9% in the SME group and three of the analyzed RME patients, in which one
40.88% 6 9.33% in the RME group). miniscrew in each patient was found to be mobile.

Table 2. Demographic and Clinical Characteristics of Patients in the SME and RME Groups
SME, n ¼ 12 RME, n ¼ 12 P Value
Demographic characteristics
Mean age at start of treatment (SD), years 14.30 (1.37) 15.07 (1.59) .218a
Sex, n
Male 4 3 1.00b
Female 8 9
Clinical characteristics
Posterior occlusion, n
Bilateral crossbite 9 11 .590c
Unilateral crossbite 2 1
Constriction without crossbite 1 0
Mean transverse discrepancy (SD), mm 4.44 (0.84) 4.66 (0.85) .799a
Mean jackscrew opening (SD), mm 5.75 (0.76) 5.90 (0.68) .617a
Mean duration of expansion (SD), days 58.50 (7.36) 16.58 (2.06) ,.0001a,d
Mean duration of retention (SD), days 90.66 (9.49) 129.66 (5.63) ,.0001a,d
a
Independent-samples t-test.
b
Fisher’s exact test.
c
Monte Carlo simulation of the Pearson v2 test.
d
Statistically significant at P  .05.

Angle Orthodontist, Vol 92, No 5, 2022

 Table 3. Skeletal and Dentoalveolar Changes From T1 to T2 in Both Groups
SME, n ¼ 12 RME, n ¼ 12 SME vs RME
T1 T2 T1–T2 T1 T2 T1–T2
Mean Mean Mean 95% CI
Mean (SD) Mean (SD) Change (SD) P Value Mean (SD) Mean (SD) Change (SD) P Value Difference Lower, Uppera P Value
Skeletal, mm
SWN-4 0.06 (0.09) 3.71 (0.82) 3.64 (0.87) .002b,c 0.09 (0.15) 3.17 (1.06) 3.08 (1.04) .002b,c 0.57 0.24, 1.38 .161d
SWP-4 0.13 (0.15) 4.08 (0.72) 3.94 (0.80) .002b,c 0.16 (0.25) 3.43 (1.11) 3.27 (1.11) .002b,c 0.67 0.15, 1.49 .103d
SW-4 0.10 (0.11) 3.89 (0.75) 3.79 (0.81) .002b,c 0.12 (0.18) 3.30 (1.08) 3.17 (1.06) .002b,c 0.62 0.18, 1.42 .124d
SWN-6 0.03 (0.07) 2.12 (0.64) 2.08 (0.68) .002b,c 0.04 (0.15) 2.75 (0.71) 2.71 (0.65) .002b,c 0.62 1.19, 0.06 .033b,d
SWP-6 0.06 (0.09) 2.39 (0.56) 2.33 (0.62) .002b,c 0.07 (0.13) 3.01 (0.73) 2.93 (0.71) .002b,c 0.60 1.17, 0.03 .042b,d
SW-6 0.04 (0.07) 2.25 (0.58) 2.21 (0.63) .002b,c 0.06 (0.11) 2.88 (0.71) 2.81 (0.66) .002b,c 0.61 1.16, 0.06 .032b,d
BBW-4 38.70 (2.91) 42.78 (3.15) 4.08 (0.93) ,.001b,e 37.77 (2.83) 41.21 (2.37) 3.43 (1.16) ,.001b,e 0.64 0.25, 1.54 .150d
BBW-6 59.00 (3.68) 61.32 (3.63) 2.32 (0.66) ,.001b,e 62.53 (3.43) 64.83 (3.20) 2.29 (0.99) ,.001b,e 0.02 0.69, 0.74 .945d
ABW-4 43.72 (3.10) 49.05 (2.96) 5.32 (0.87) ,.001b,e 41.84 (2.51) 46.61 (2.34) 4.76 (1.42) ,.001b,e 0.56 0.45, 1.65 .263d
ABW-6 54.32 (4.18) 58.66 (3.97) 4.33 (1.05) ,.001b,e 55.17 (3.46) 59.76 (3.18) 4.59 (1.60) ,.001b,e 0.26 1.41, 0.89 .642d
Dentoalveolar linear, mm
Apex-4 27.41 (2.05) 33.04 (1.85) 5.63 (0.94) ,.001b,e 26.18 (2.33) 30.50 (2.21) 4.32 (2.01) ,.001b,e 1.31 0.03, 2.64 .055d
Apex-6 29.14 (2.20) 34.32 (2.45) 5.18 (0.85) ,.001b,e 28.28 (2.92) 32.39 (2.71) 4.11 (1.29) ,.001b,e 1.08 0.15, 2.01 .025b,d
SLOW VS RAPID MINISCREW-SUPPORTED EXPANSION

Cusp-4 28.23 (3.18) 34.48 (3.13) 6.24 (0.79) ,.001b,e 25.53 (3.17) 31.94 (2.98) 6.41 (0.98) ,.001b,e 0.16 0.92, 0.59 .658d
Cusp-6 36.44 (3.07) 41.46 (2.60) 5.02 (1.74) ,.001b,e 33.97 (3.75) 40.89 (3.24) 6.91 (0.93) ,.001b,e 1.89 3.07, 0.72 .003b,d
Dentoalveolar angular, 8
RtDentInc-4 92.43 (6.99) 95.02 (6.88) 2.59 (2.47) .004b,e 90.54 (7.23) 93.48 (7.01) 2.93 (2.68) .003b,e 0.34 2.53, 1.84 .671f
LtDentInc-4 93.67 (8.81) 94.75 (9.62) 1.07 (2.04) .096e 91.79 (5.74) 96.25 (7.78) 4.45 (4.32) .004e 3.38 6.25, 0.52 .033b,f
RtDentInc-6 103.36 (4.03) 103.47 (3.44) 0.11 (2.43) .881e 103.90 (4.98) 107.83 (6.18) 3.93 (3.29) .002b,e 3.83 6.28, 1.37 .001b,f
LtDentInc-6 105.30 (7.51) 105.60 (6.55) 0.29 (2.40) .683e 107.35 (7.11) 109.68 (7.54) 2.32 (1.59) ,.001b,e 2.03 3.76, 0.30 .014b,f
RtAlvInc-4 111.19 (12.22) 113.60 (11.19) 2.41 (2.51) .007b,e 107.68 (8.41) 110.63 (8.13) 2.95 (2.34) .001b,e 0.53 2.59, 1.53 .799f
LtAlvInc-4 113.68 (16.50) 115.68 (15.92) 1.99 (2.54) .020b,e 108.16 (9.97) 112.35 (10.82) 4.18 (2.65) ,.001b,e 2.19 4.39, 0.02 .039b,f
RtAlvInc-6 104.46 (3.85) 107.22 (3.05) 2.75 (1.94) ,.001b,e 104.02 (4.17) 107.69 (3.74) 3.66 (2.30) ,.001b,e 0.91 2.71, 0.89 .114f
LtAlvInc-6 104.70 (7.40) 106.45 (6.11) 1.75 (1.94) .010b,e 106.11 (5.23) 108.84 (5.64) 2.72 (2.55) .003b,e 0.98 2.90, 0.95 .291f
a
CI indicates confidence interval.
b
Statistically significant at P  .05.
c
Values are compared using a Wilcoxon signed-rank test.
d
Groups are compared using an independent-samples t-test.
e
Values are compared using a paired t-test.
f
Groups are compared using a Mann-Whitney U-test.

Angle Orthodontist, Vol 92, No 5, 2022

585
586 YACOUT, ABDALLA, EL HAROUNY

Miniscrew bending was observed in five miniscrews some studies6,8,24 reported significant buccal tipping,
after retrieval from five different RME patients. whereas others7,10,11 did not find a significant change.
The different miniscrew positions25 and the manner of
DISCUSSION connection between the expansion screw and the
miniscrews26 may affect stress distribution and hence
Although miniscrew-supported maxillary expanders
skeletal and dentoalveolar expansion effects of the
were initially described more than a decade ago,5 there
appliance.
is a lack of consensus regarding their optimal
Intergroup comparison showed that RME resulted in
activation rate.15 Therefore, this RCT was conducted
significantly greater sutural expansion at the level of
to compare slow and rapid activation protocols of
miniscrew-supported maxillary expanders. first molars compared with SME. However, the
Separation of the mid-palatal suture, as evidenced difference between the groups was small and not
by the appearance of a midline diastema, and clinically significant. Other skeletal readings were not
correction of the skeletal discrepancy were accom- significantly different between the two groups, nor was
plished in all analyzed patients. The residual dental the percentage of skeletal expansion at the level of first
crossbite reported at the end of expansion in two SME molars. Previous RCTs27–29 reported more skeletal
patients may be a manifestation of mandibular inter- expansion with RME than SME; however, those
molar width increase. Previous research showed that studies evaluated conventional tooth-supported ex-
mandibular intermolar width significantly increased panders.
following expansion using bone-borne expanders14 The amount of jackscrew opening in the current
and tissue-bone-borne expanders.20 study was based on the individual treatment needs of
Miniscrew failure encountered with RME may be each patient. Therefore, the percentage of sutural
attributed to bone micro-fractures that might have expansion relative to jackscrew opening was calculat-
resulted from an accumulation of stresses in the bone ed for SME (38.99%) and RME (48.58%). No
around miniscrews with rapid activation, whereas the significant difference was found between the two
slow rate of activation in the SME patients might have groups. Previous research on miniscrew-supported
allowed the dissipation of such stresses.13,21 A recent expanders has shown that skeletal expansion and
study showed that the 12-month survival rate for jackscrew opening do not take place in a 1:1 ratio.7,8,11
palatal miniscrews used for maxillary expansion was The disparity between the amount of sutural expansion
lower than survival rates for palatal miniscrews used and jackscrew opening can be explained by the build-
for other orthodontic purposes.22 The authors attributed up of force that takes place until it is enough to
this to the high forces generated by RME. Similarly, overcome the resistance of the skeletal structures,
miniscrew bending may be related to rapid activation which is evident clinically when multiple activations are
possibly causing the build-up of forces at the mini- made before separation of the mid-palatal suture takes
screws,13,21 resulting in increased flexural load. place.30
In the current study, SME resulted in significant Dental inclination of the first premolars and first
skeletal and dental expansion. Similar results were molars changed in both groups despite not being
previously reported by Lagravère et al.5 using the same directly attached to the expansion appliances. A part of
activation protocol; however, they reported a smaller this change may be attributed to the rotation of the
increase in interpremolar width (1.92 mm) than maxillary halves laterally.31 RME resulted in a greater
reported in the current study (6.24 mm). This may be dental inclination change compared with SME. In RME,
attributed to different expander designs. The appliance the increase in Cusp-6 (6.91 mm) was higher than
was anchored using only two posterior miniscrews,5 Apex-6 (4.11 mm), suggesting dental tipping. However,
whereas in the current study, two additional miniscrews in SME, the increase in Apex-6 (5.18 mm) was
were placed anteriorly in addition to acrylic pads, which comparable to Cusp-6 (5.02 mm), suggesting a more
may have resulted in more expansion anteriorly. bodily pattern of expansion.
RME resulted in significant skeletal expansion as Regarding the increase in alveolar inclination, no
evidenced by the increase in basal bone width of the significant difference was found between the two
maxilla at the first premolars and first molars. Analo- groups except for the left first premolar measurement,
gous results were obtained in previous studies suggesting that treatment with either SME or RME
investigating RME using the same appliance design.6,23 results in significant alveolar bone bending. Published
Significant buccal tipping of the first premolars and first research has previously demonstrated that such an
molars took place with RME in the current study. The increase in alveolar inclination is a common finding
amount of dental and alveolar tipping reported with with the expansion appliance used in the current
miniscrew-supported RME is controversial, where study.6,23

Angle Orthodontist, Vol 92, No 5, 2022

SLOW VS RAPID MINISCREW-SUPPORTED EXPANSION 587

Limitations 8. Akin M, Akgul YE, Ileri Z, Basciftci FA. Three-dimensional

evaluation of hybrid expander appliances: a pilot study.
Double blinding was not possible because of the Angle Orthod. 2016;86(1):81–86.
nature of the clinical procedures. The statistician, 9. Celenk-Koca T, Erdinc AE, Hazar S, Harris L, English JD,
however, was blinded during data assessment. Akyalcin S. Evaluation of miniscrew-supported rapid maxil-
Comparison of the study results with previously lary expansion in adolescents: a prospective randomized
clinical trial. Angle Orthod. 2018;88(6):702–709.
published research was challenging because of the 10. Rojas V, Macherone C, Zursiedel MI, Valenzuela JG. Rapid
variability in appliance designs and lack of uniformity in maxilary expansion in young adults: comparison of tooth-
the landmarks used. borne and bone-borne appliances, a cohort study. J Oral
Res. 2019;8(3):201–209.
Generalizability 11. Annarumma F, Posadino M, De Mari A, et al. Skeletal and
dental changes after maxillary expansion with a bone-borne
Results can be generalized to adolescents having no appliance in young and late adolescent patients. Am J
congenital craniofacial malformations and no systemic Orthod Dentofacial Orthop. 2021;159(4):e363–e375.
diseases affecting bone metabolism. 12. Cannavale R, Chiodini P, Perillo L, Piancino MG. Rapid
palatal expansion (RPE): meta-analysis of long-term effects.
Orthod Craniofac Res. 2018;21(4):225–235.
CONCLUSIONS 13. Trojan L, Gonzalez-Torres L, Melo A, de Las Casas E.
 Both slow and rapid rates of miniscrew-supported Stresses and strains analysis using different palatal expand-
er appliances in upper jaw and midpalatal suture. Artif
maxillary expander activation were successful in
Organs. 2017;41(6):E41–E51.
correcting the transverse maxillary deficiency, with 14. Canan S, S  enıs ık NE. Comparison of the treatment effects
SME resulting in less complications than RME. of different rapid maxillary expansion devices on the maxilla
and the mandible. Part 1: evaluation of dentoalveolar
changes. Am J Orthod Dentofacial Orthop. 2017;151(6):
ACKNOWLEDGMENTS 1125–1138.
The authors thank Assistant Professor Hassan Kassem for his 15. Hassan M, Yacout Y, El-Harouni N, Ismail H, Abdallah E,
insightful suggestions and Dr. Hams Abdelrahman for performing Zaher A. Effect of activation protocol on miniscrew-assisted
the statistical analysis. palatal expansion: a systematic review of current evidence.
Egypt Dent J. 2021;67(2):987–1000.
16. Cantarella D, Dominguez-Mompell R, Mallya SM, et al.
REFERENCES Changes in the midpalatal and pterygopalatine sutures
1. Korbmacher H, Huck L, Merkle T, Kahl-Nieke B. Clinical induced by micro-implant-supported skeletal expander,
profile of rapid maxillary expansion—outcome of a national analyzed with a novel 3D method based on CBCT imaging.
inquiry. J Orofac Orthop. 2005;66(6):455–468. Prog Orthod. 2017;18(1):34.
2. Rungcharassaeng K, Caruso JM, Kan JY, Kim J, Taylor G. 17. Sealed Envelope Ltd. Create a blocked randomisation list.
Available at: https://www.sealedenvelope.com/simple-
Factors affecting buccal bone changes of maxillary posterior
randomiser/v1/lists. Accessed January 13, 2019.
teeth after rapid maxillary expansion. Am J Orthod Dento-
18. Paredes N, Colak O, Sfogliano L, et al. Differential
facial Orthop. 2007;132(4):428 e1–e8.
assessment of skeletal, alveolar, and dental components
3. Baysal A, Karadede I, Hekimoglu S, et al. Evaluation of root
induced by microimplant-supported midfacial skeletal ex-
resorption following rapid maxillary expansion using cone-
pander (MSE), utilizing novel angular measurements from
beam computed tomography. Angle Orthod. 2012;82(3):
the fulcrum. Prog Orthod. 2020;21(1):18.
488–494.
19. Koo TK, Li MY. A guideline of selecting and reporting
4. Garib DG, Henriques JF, Janson G, de Freitas MR,
intraclass correlation coefficients for reliability research. J
Fernandes AY. Periodontal effects of rapid maxillary Chiropr Med. 2016;15(2):155–163.
expansion with tooth-tissue-borne and tooth-borne expand- 20. Yılmaz A, Arman-Özçırpıcı A, Erken S, Polat-Özsoy O.
ers: a computed tomography evaluation. Am J Orthod Comparison of short-term effects of mini-implant-supported
Dentofacial Orthop. 2006;129(6):749–758. maxillary expansion appliance with two conventional expan-
5. Lagravère MO, Carey J, Heo G, Toogood RW, Major PW. sion protocols. Eur J Orthod. 2015;37(5):556–564.
Transverse, vertical, and anteroposterior changes from 21. Seong EH, Choi SH, Kim HJ, Yu HS, Park YC, Lee KJ.
bone-anchored maxillary expansion vs traditional rapid Evaluation of the effects of miniscrew incorporation in palatal
maxillary expansion: a randomized clinical trial. Am J Orthod expanders for young adults using finite element analysis.
Dentofacial Orthop. 2010;137(3):304.e1–e12. Korean J Orthod. 2018;48(2):81–89.
6. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G. Tooth- 22. Arqub SA, Gandhi V, Mehta S, Palo L, Upadhyay M, Yadav
borne vs bone-borne rapid maxillary expanders in late S. Survival estimates and risk factors for failure of palatal
adolescence. Angle Orthod. 2015;85(2):253–262. and buccal mini-implants. Angle Orthod. 2021;91(6):756–
7. Mosleh MI, Kaddah MA, Abd ElSayed FA, ElSayed HS. 763.
Comparison of transverse changes during maxillary expan- 23. Moon HW, Kim MJ, Ahn HW, et al. Molar inclination and
sion with 4-point bone-borne and tooth-borne maxillary surrounding alveolar bone change relative to the design of
expanders. Am J Orthod Dentofacial Orthop. 2015;148(4): bone-borne maxillary expanders: a CBCT study. Angle
599–607. Orthod. 2020;90(1):13–22.

Angle Orthodontist, Vol 92, No 5, 2022

588 YACOUT, ABDALLA, EL HAROUNY

24. Oh H, Park J, Lagravere Vich MO. Comparison of traditional 28. Pereira JDS, Jacob HB, Locks A, Brunetto M, Ribeiro GLU.
RPE with two types of micro-implant assisted RPE: CBCT Evaluation of the rapid and slow maxillary expansion using
study. Semin Orthod. 2019;25(1):60–68. cone-beam computed tomography: a randomized clinical
25. Choi JY, Choo H, Oh SH, Park JH, Chung KR, Kim SH. trial. Dental Press J Orthod. 2017;22(2):61–68.
Finite element analysis of C-expanders with different vertical 29. Ribeiro GLU, Jacob HB, Brunetto M, Pereira JDS, Motohiro
vectors of anchor screws. Am J Orthod Dentofacial Orthop. Tanaka O, Buschang PH. A preliminary 3-D comparison of
2021;159(6):799–807.
rapid and slow maxillary expansion in children: a random-
26. Lee HK, Bayome M, Ahn CS, et al. Stress distribution and
ized clinical trial. Int J Paediatr Dent. 2020;30:349–359.
displacement by different bone-borne palatal expanders with
micro-implants: a three-dimensional finite-element analysis. 30. Zimring JF, Isaacson RJ. Forces produced by rapid maxillary
Eur J Orthod. 2014;36(5):531–540. expansion: III. Forces present during retention. Angle
27. Martina R, Cioffi I, Farella M, et al. Transverse changes Orthod. 1965;35(3):178–186.
determined by rapid and slow maxillary expansion—a low- 31. Starnbach H, Bayne D, Cleall J, Subtelny JD. Facioskeletal
dose CT-based randomized controlled trial. Orthod Cranio- and dental changes resulting from rapid maxillary expan-
fac Res. 2012;15(3):159–168. sion. Angle Orthod. 1966;36(2):152–164.

Angle Orthodontist, Vol 92, No 5, 2022