Adult palatal expansion: MARPE, SARME and DOME

Widening an adult palate is a direct way to expand the nasal floor. There are three ways to do it: with micro-implants without osteotomy (MARPE/MSE), with operating room surgical assistance (SARME/SARPE), or with an intermediate protocol designed specifically for sleep apnea (DOME). They have different scientific evidence and suit different anatomical profiles.

Adult palatal expansion with mini-implants (DOME / MARPE) — Illustration of maxillary expansion with micro-implants and midpalatal suture response. Explanatory medical illustration validated by Dr. Méndez-Benegassi.

Why is the palate directly connected to the nose?

Because the roof of the mouth is the floor of the nose. It is the exact same bone viewed from two sides: the hard palate. If that bony arch is narrow and high (ogival palate), the nasal airway resting on top of it is structurally constricted.

Nasal airflow restriction:

A narrow nasal floor forces inhaled air through a constricted tube, increasing nasal resistance during sleep.

Tongue space restriction:

A high, vaulted palate prevents the tongue from resting firmly against the oral roof, predisposing it to fall back into the throat.

Why child expanders fail in adults

In children, the midpalatal suture has not fused and yields easily under light dental forces. In adults, the suture progressively interlocks and calcifies with age [1].

When an adult is fitted with a conventional tooth-borne expander, the bone resists and the teeth simply tip outwards. Even with surgical assistance, the widening measured in adults is greatest at the dental arch, smaller at the palatal bone and smallest at the nasal floor — a V-shaped opening [9]. Much of what moves are tipped teeth, not expanded nasal floors.

To achieve skeletal expansion in an adult, force must be anchored directly into bone with mini-screws (MARPE), assisted by surgical bone releases (SARME), or combined in a targeted sleep apnea protocol (DOME).

The three techniques compared

1. MARPE / MSE (Microtornillos sin osteotomía)

An expander anchored into the palatal bone using 4 bicortical miniscrews. Performed in the orthodontic office under local anesthesia without operating room surgery [5][8].

Target profile: Late adolescents and young adults with open sutures.
Limitations: The midpalatal suture interlocks and fuses with age, so staging it on 3D imaging is what decides eligibility; if the suture fails to separate, the force is absorbed by the teeth [2].

2. SARME / SARPE (Expansión asistida quirúrgicamente)

Traditional maxillofacial surgery involving a subtotal Le Fort I osteotomy with or without pterygomaxillary dysjunction under general anesthesia in the OR [10].

Target profile: Severe transverse deficiency (>5 mm) with fully fused suture.
Evidence note: Developed to fix bites, not primarily for sleep apnea. The respiratory evidence comes from small series: in 16 adults with OSA, the respiratory disturbance index fell from 35.4 to 16.0 events/h [11].

3. DOME (Distracción osteogénica específica para apnea)

Designed at Stanford specifically for sleep apnea patients with high vaulted palates. Combines a mini-implant expander with minimal targeted corticotomies under local/sedation or outpatient anesthesia [3][4].

Clinical outcomes: In a selected series of 75 patients, mean AHI dropped from 17.7 to 8.2 events/h (about 54%) and the NOSE nasal obstruction score from 10.9 to 3.3 out of 20 [4].
Context: Series come from specialized academic centers; no published multi-center trials in Spain to date.

What palatal expansion does NOT solve

Widening the palate opens the nose and gains space for the anterior tongue. However, it does not prevent collapse of the retrobasal tongue or epiglottis during sleep.

That is why drug-induced sleep endoscopy (DISE) is mandatory: if dynamic collapse is identified behind the tongue or at the pharyngeal walls, other therapies such as mandibular advancement or targeted surgery may be needed.sleep endoscopy (DISE) is essential to observe where and how collapse occurs.

Frequently Asked Questions

Can an adult palate be widened without surgery?

Only if the midpalatal suture has not yet fully fused, as evaluated with a dental CBCT scan. In late adolescents and selected young adults, miniscrew-assisted expansion (MARPE) can separate the suture without osteotomies. When the suture is fully interlocked, skeletal expansion requires surgical assistance (SARME or DOME); otherwise, the appliance merely tips teeth.

Does widening the palate improve nasal breathing?

Yes. The roof of the mouth is the floor of the nose. Skeletal expansion widens the nasal cavity and internal nasal valve, documented by significant drops in nasal obstruction scores (NOSE questionnaire) across multiple series.

Will expanding the palate cure my sleep apnea?

It rarely acts as a standalone cure in unselected patients. In Yoon’s DOME series of 75 selected patients with a narrow maxilla and nasal floor, mean AHI decreased from 17.7 to 8.2 events/h (about a 54% reduction). If dynamic collapse occurs behind the tongue base or at the epiglottis, additional treatments are required.

What is the main difference between SARME and DOME?

SARME was developed in oral and maxillofacial surgery primarily to correct crossbites and dental crowding, utilizing full Le Fort I osteotomies. DOME was designed specifically for sleep apnea patients with high vaulted palates, combining mini-implants with targeted minimal corticotomies and an outpatient protocol.

Is there an age limit for adult palatal expansion?

Chronological age alone does not decide eligibility; suture maturation staging on 3D imaging does. While MARPE success drops past age 25-30, surgically assisted methods (SARME and DOME) can be successfully performed in mature adults.

How long does the entire expansion process take?

Active appliance expansion takes between 3 to 8 weeks. However, complete treatment requires leaving the expander in place for several months for bone consolidation, followed by conventional orthodontics to align the bite.

Clinical evaluation and coordination

The sleep study and upper airway dynamic evaluation are performed by the sleep ENT surgeon. If skeletal transverse deficiency is confirmed, treatment is planned in close coordination with oral and maxillofacial surgery and specialized orthodontics.

Videosomnoscopy (DISE) →Maxillomandibular advancement guide →

Scientific References

Melsen B. Palatal growth studied on human autopsy material. A histologic microradiographic study. Am J Orthod. 1975;68(1):42-54. PMID 1056143
Angelieri F, Cevidanes LHS, Franchi L, Gonçalves JR, Benavides E, McNamara JA. Midpalatal suture maturation: classification method for individual assessment before rapid maxillary expansion. Am J Orthod Dentofacial Orthop. 2013;144(5):759-769. PMID 24182592
Liu SY, Guilleminault C, Huon LK, Yoon A. Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients with High Arched Palate. Otolaryngol Head Neck Surg. 2017;157(2):345-348. PMID 28675100
Yoon A, Guilleminault C, Zaghi S, Liu SY. Distraction Osteogenesis Maxillary Expansion (DOME) for adult obstructive sleep apnea patients with narrow maxilla and nasal floor. Sleep Med. 2019;65:172-176. PMID 31606311
Cantarella D, Dominguez-Mompell R, Mallya SM, et al. Changes in the midpalatal and pterygopalatine sutures induced by micro-implant-supported skeletal expander, analyzed with a novel 3D method based on CBCT imaging. Prog Orthod. 2017;18(1):34. PMID 29090368
Camacho M, Chang ET, Song SA, et al. Rapid maxillary expansion for pediatric obstructive sleep apnea: A systematic review and meta-analysis. Laryngoscope. 2017;127(7):1712-1719. PMID 27796040
Mehta S, Wang D, Kuo CL, et al. Long-term effects of mini-screw-assisted rapid palatal expansion on airway. Angle Orthod. 2021;91(2):195-205. PMID 33315060
Brunetto DP, Moschik CE, Dominguez-Mompell R, Jaria E, Sant'Anna EF, Moon W. Mini-implant assisted rapid palatal expansion (MARPE) effects on adult obstructive sleep apnea (OSA) and quality of life: a multi-center prospective controlled trial. Prog Orthod. 2022;23(1):3. PMID 35102477
Zandi M, Miresmaeili A, Heidari A. Short-term skeletal and dental changes following bone-borne versus tooth-borne surgically assisted rapid maxillary expansion: a randomized clinical trial study. J Craniomaxillofac Surg. 2014;42(7):1190-1195. PMID 24704281
Pereira MD, Koga AF, Prado GPR, Ferreira LM. Complications From Surgically Assisted Rapid Maxillary Expansion With HAAS and HYRAX Expanders. J Craniofac Surg. 2018;29(2):275-278. PMID 29077680
Vinha PP, Eckeli AL, Faria AC, Xavier SP, de Mello-Filho FV. Effects of surgically assisted rapid maxillary expansion on obstructive sleep apnea and daytime sleepiness. Sleep Breath. 2016;20(2):501-508. PMID 26092279
Abdelwahab M, Yoon A, Okland T, Poomkonsarn S, Gouveia C, Liu SY. Impact of Distraction Osteogenesis Maxillary Expansion on the Internal Nasal Valve in Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2019;161(2):362-367. PMID 31084256
De Vito A, Carrasco Llatas M, Ravesloot MJ, et al. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol. 2018;43(6):1541-1552. PMID 30133943

Adult palatal expansion: MARPE, SARME and DOME in sleep apnea