Is there an age limit for placing a MARPE?

Maxillary compression is a relatively frequent problem seen in our daily practice. This osseodental discrepancy presented by the patient can be treated in different ways depending on its severity and, of course, depending on the patient's age. In fact, we usually use age as a reference to roughly determine the maturation of the sutures, but... have you ever wondered if this approach is accurate?

Among the treatments available to resolve maxillary compression, in addition to dentoalveolar compensation, we can use devices such as Hyrax, McNamara, MARPEs or surgical treatments (SARPE) in patients with fused sutures.

The maturation of the palatal suture is the main reference or "guide" that we will use to establish the most appropriate treatment for that patient. If we review the studies on this subject, we can see that there is a certain association between the level of maturation of the suture and the age of the patient, but this association does not hold true for all individuals equally. We can find 15 year old patients with a completely fused suture and we can find 50 year old patients with a partially open suture. Another detail to take into account is that this is not the only suture that we have to separate to achieve a disjunction, but there are more sutures to take into account: the circummaxillary sutures. The analysis of these sutures is more complex, so in this case we will be guided by the patient's age to establish their approximate maturity.

Classification of the different stages of sutural maturation (A-3) in relation to the patient's growth.  

What can we deduce from all this? That the decision to place a tooth-supported disjunctor, to place a MARPE or to perform surgery is not a simple one, because it is always accompanied by a certain degree of uncertainty, even if we analyse the suture. That is why CBCT becomes a key test for these treatments. Depending on the state of maturation of the suture, we can determine which option is recommended. If the patient has a suture in stage A or B, which is usually present in patients between 6 and 12 years of age, with a tooth-supported disjunctor, we will be able to achieve adequate dental expansion. When we enter more advanced stages, such as stage C, an osseous-supported disjunctor will give us a greater guarantee of expanding the maxilla. This stage of maturation usually appears in the post-pubertal period. Stages D and E, which are more common in adults, are the most advanced and even with a MARPE we will not always be able to achieve expansion.

In some cases, where the patient is at an early stage of maturation, the MARPE will also be the treatment of choice: if we are treating maxillary hypoplasia in a skeletal Class III patient, the MARPE offers numerous advantages over a tooth-supported bracket. The MARPE allows skeletal anchorage to be obtained, achieving better control of expansion, reducing the undesired effects on the teeth where a tooth-supported bracket would be supported (vestibular overturning of the crowns and possible recessions or dehiscence associated with them due to the loss of thickness of the vestibular cortex). 

In addition, maxillary traction will have a greater effect on the maxilla and less mesialisation and proinclination of the upper incisors thanks to this skeletal support, which will have a positive effect on the aesthetics of the patient's smile. Therefore, we should not be "afraid" to place a MARPE in a child with a Class III, as a maxillary traction with bone support will be more beneficial for the patient in the medium and long term. 

In cases of adult patients with maxillary hypoplasia we may also have doubts. We have already seen that there is no age limit, as age does not always correlate with the maturation of the suture. As an estimate, we could say that between 20-30 years of age it is feasible to treat a patient with MARPE and that, statistically, those over 30 years of age will have less chance of MARPE working. If we combine these data with the analysis of suture maturation with CBCT, reviewing several slices at different heights, we will achieve a more accurate diagnosis and, therefore, a more accurate treatment strategy. 

MARPEs are devices that cannot be fitted lightly, as they will cause bone changes in very delicate structures. For this reason, although we cannot guarantee our treatments, it is advisable that we make an effort to carefully analyse each case in order to reduce as far as possible all the risks that may arise when these devices do not work.

Guglielmo B et al. A clinician's perspective on indications and failures of bone-borne maxillary expanders. Seminars in Orthodontics (2023) 1-7.

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