Disclaimer: The remarks that follow are heavily influenced by my own experience in orthodontics, which predates temporary anchorage devices of any kind by decades. Readers should know that I expanded my own maxilla 7 mm non-surgically and without TADs in the early 1990s, as well as my wife’s maxilla approximately 10 mm non-surgically and without TADs. To do this I also had to broaden our lower arches. I clearly heard my ortho instructors telling me that the adult maxilla cannot be expanded and the mandible should never be expanded. I’ve also read articles in the refereed literature — including one from a former AAO President — stating that the adult maxilla cannot be expanded without a surgical assist. I wear glasses and have read such articles.
In my career I was fortunate to have mentors who pushed the narrow boundaries of what orthodontists are taught. I also realized that the people who taught us these “limits” had never tested them — just as those who taught them had never done so. When you meet highly successful orthodontists who have tested these supposed limits and have expanded adult maxillas 10+ mm non-surgically and without any anchorage device, it is natural to be skeptical. If you look at their results, it may dawn on you that it is actually possible. If you are curious enough to try something you were taught was impossible, you might find it really is possible.
I’ve expanded a number of adults massively without surgery and without MARPE and have a number of documented cases in lecture form. I’ve also done surgically assisted adult expansion since the 1980s — before most people reading this were born — and have those cases to show as well.
It is hard to go even a few days looking at email or social media without seeing MARPE being advocated or taught. If MARPE were ice cream, it would not be the flavor of the month — it would be the flavor of the decade.
Do I think there is a place for MARPE? Yes, I actually do.
Many of the most challenging patients to help are those who had bicuspid extraction and retractive orthodontics as adolescents. The entire growth direction of their faces is often predominantly vertical rather than a favorable forward direction. I’ve seen hundreds of such patients with very poor airways and symptom patterns including OSA ranging from mild to severe. I’ve been treating these patients for nearly 4 decades and know that regaining tongue space and airway can be very challenging. Many cases require surgery. Some can benefit from re-opening previous orthodontic spaces to regain tongue space, and that may be all that some need. Others will require surgery with orthodontic preparation.
In patients with severely shortened roots from previous orthodontics, I consider it a poor idea to risk further resorption through extensive ortho required to re-open spaces. The last thing I want is for them to experience further resorption and lose teeth.
I also know that taking a very narrow maxilla after extraction and retraction and simply doing MMA surgery — without maximizing tongue space first — may fall far short of success. I’ve seen those failures from some very good surgeons and even from university-based teaching programs. My firm belief is that the skyscraper is no better than the foundation it is built on. In such cases, massive lateral expansion of both arches might help achieve better surgical outcomes. The patient can more easily get the tongue to the palate and keep it there at rest if the “garage” the tongue lives in is larger.
MARPE combined with midline distraction of the mandible to achieve substantial mandibular lateral expansion may be the solution in these cases. This is a great place for MARPE, and I highly recommend it.
I’ve had students in my mentorship programs who were taught that MARPE is needed for young kids to facilitate expansion. When I show them a pre-adolescent that I expanded 17 mm without TADs or surgery, their jaws drop.
There are places for most everything in our profession. Nothing should be done without a thorough diagnosis and a survey of all available options. If the only expansion option someone has been taught is MARPE, there is a pretty good chance that MARPE will be recommended almost every time. A sledgehammer can be an effective tool to kill a mosquito. I’ve used the palm of my hand to do that my whole life. Which would you prefer?
