Expanding Wallets With Palates: The Evidence Problem with MARPE and Palatal Expansion in Treating TMJ Problems
“Palatal expansion is a great orthodontic treatment modality, but it should not be marketed as a cure-all for TMJ Disorders and Sleep Apnea".
If I had a nickel every time I heard this story: patient walks into a dental office of someone not board certified or residency trained specialist in oral medicine, orofacial pain or oral surgery and seeks relief from jaw pain; and walks out with a five-figure treatment plan for Miniscrew-Assisted Rapid Palatal Expansion (MARPE) or surgically assisted expansion. The promise? “We’ll expand your upper jaw and roof of your mouth (palate), open your airway, and that will fix your TMJ.” But rigorous scientific evidence supporting a cure for TMD by expanding the palate in adults is lacking.
The Promise of a “Permanent Fix”
For someone exhausted from poor sleep or grappling with daily jaw pain, the idea of a one-time, permanent fix is tempting. The narrative of palatal expansion sounds elegant: widen the jaw, increase airway space, and miraculously, relief.
What Are MARPE and Palatal Expansion
MARPE (Miniscrew-Assisted Rapid Palatal Expansion) uses mini-implants to apply force directly to the maxillary bone, bypassing teeth. It's primarily an orthodontic tool for expanding narrow upper jaws, in growing patients. Since adults typically have a fused midpalatal suture, expansion in this age group is either surgical (SARPE) or experimentally non-surgical via MARPE and can be accompanied by discomfort, prolonged treatment, and higher costs [1,2].
Where the Evidence Says
Limited High-Quality Research:
A recent MARPE review highlighted the scarcity of randomized controlled trials investigating MARPE's efficacy in adults, with most studies conducted on small samples or retrospective designs [3].
Meta-Analytic Data:
Meta-analyses reveal that MARPE can increase nasal and nasopharyngeal airway volumes, but these clinical increases are inconsistent and unpredictable. Clinical outcomes such as a decrease in sleep apnea score, the apnea-hypopnea index (AHI) do not predictably occur [4].
Clinical Trials:
A multicenter prospective controlled study demonstrated some improvement in AHI and quality of life measures in non-obese adults with sleep apnea after MARPE, yet sample sizes were limited, and the study acknowledged the need for longer follow-up and larger sample sizes of subjects [5].
Risks and Costs
MARPE and/or SARPE procedures are expensive (often exceeding $15,000), invasive, and carry risks such as root resorption, periodontal damage, and relapse [6]. Furthermore, less expensive and validated treatments like CPAP and oral devices for sleep apnea and oral appliance therapy for TMJ disorders may be delayed in patients in whom providers promise cures using MARPE, potentially worsening their condition [7].
Simpler, Cheaper and Evidence-Based Care
Adults with TMD or obstructive sleep apnea should be treated by evidence-based therapies. CPAP and oral devices that advance the lower jaw when sleeping are effective alternatives therapies for sleep apnea [7,8]. Interdisciplinary care involving sleep medicine, ENT, oral medicine, and physical therapy provides better outcomes in treating TMD and sleep apnea. Palatal expansion is a great orthodontic treatment modality, but it should not be marketed as a cure-all for TMJ Disorders and Sleep Apnea. Until robust long-term clinical studies are available, clinicians and patients should demand transparency and rely on evidence-based care.
Or perhaps I abandon my belief in evidence-based care and advocate MARPE to treat facial pain and sleep apnea - it can certainly help upgrade my Toyota Rav4 Hybrid.
References
[1] Angelieri, F., Cevidanes, L. H. S., & Camacho, M. (2020). Miniscrew-assisted rapid palatal expansion: A comprehensive review. Progress in Orthodontics, 21(1), 34. https://doi.org/10.1186/s40510-020-00331-4
[2] Bortolotti, F., Turra, F., & Castaldo, A. (2021). Surgical assisted rapid palatal expansion in adults: A review. European Journal of Orthodontics, 43(3), 326–337. https://doi.org/10.1093/ejo/cjab015
[3] Camargo, P. R., Martinez, M. M., & Barbosa, I. R. (2023). Impact of miniscrew-assisted rapid palatal expansion in adult patients: A scoping review. Dental Press Journal of Orthodontics, 28(1), e2300060. https://doi.org/10.1590/2177-6709.28.1.e2300060.oar
[4] Al-Mozany, M., Kairalla, M., Abdel-Fattah, M., & Kearney, R. (2021). The effect of miniscrew-assisted rapid palatal expansion on upper airway dimensions: A systematic review and meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics, 160(4), 506–518. https://doi.org/10.1016/j.ajodo.2020.12.019
[5] Lee, S. W., Cho, H. J., & Kim, Y. (2022). The effects of MARPE on sleep apnea: A multicenter prospective study. Progress in Orthodontics, 23(1), 15. https://doi.org/10.1186/s40510-022-00409-2
[6] Cantarella, D., Dominguez, A., & Manni, A. (2019). SARPE in adults: Complications and outcomes. International Journal of Oral and Maxillofacial Surgery, 48(10), 1325–1333. https://doi.org/10.1016/j.ijom.2019.05.006
[7] Ramar, K., Dort, L. C., Katz, S. G., Lettieri, C. J., Harrod, C. G., Thomas, S. M., & Chervin, R. D. (2015). Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. Journal of Clinical Sleep Medicine, 11(7), 773–827. https://doi.org/10.5664/jcsm.4858
[8] Epstein, L. J., Kristo, D., Strollo, P. J., Friedman, N., Malhotra, A., Patil, S. P., ... & Weaver, T. E. (2009). Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. Journal of Clinical Sleep Medicine, 5(3), 263–276. https://doi.org/10.5664/jcsm.27497
