Can an adult with osteoporosis undergo palatal expansion?

Palatal Expansion in Adults with Osteoporosis

Yes, adults with osteoporosis can undergo palatal expansion, but the approach must be carefully selected based on age, severity of transverse deficiency, and bone quality, with miniscrew-assisted rapid palatal expansion (MARPE) or slow expansion protocols preferred over traditional rapid expansion to minimize complications in compromised bone.

Treatment Options by Severity

Non-Surgical Approaches (Preferred in Osteoporosis)

Miniscrew-Assisted Rapid Palatal Expansion (MARPE) is the most appropriate option for adults with osteoporosis, as it has been successfully demonstrated even in patients up to 50 years of age 1. This technique:

• Uses 4 orthodontic miniscrews anchored to bone rather than relying solely on dental anchorage 1
• Achieves parallel skeletal expansion without excessive dental tipping 1
• Should employ a slow expansion protocol rather than rapid activation to accommodate reduced bone density 1
• Requires extended retention periods (potentially 20+ months) due to slower bone mineralization in the midpalatal suture 1

Rapid Maxillary Alveolar Expansion (RMAE) using a Haas appliance can achieve 3.9-7.5 mm of transmolar expansion in adults 2. Critical modifications for osteoporotic patients include:

• Limiting the rate of appliance activation to avoid pain, swelling, and ulceration 2
• Understanding that most correction occurs at the alveolar process level rather than the skeletal base 2
• Accepting modest molar tipping and minimal gingival recession as expected outcomes 2

Surgical Approach (When Non-Surgical Fails)

Surgically-Assisted Rapid Palatal Expansion (SARPE) should be reserved for cases where non-surgical methods are contraindicated or have failed 3, 4. However, this presents specific concerns in osteoporosis:

• Bone density in the midpalatal suture reaches only 48-75% of preoperative values at 7 months post-SARPE 5
• Retention time must be significantly lengthened beyond standard protocols due to delayed bone regeneration 5
• The posterior midpalatal suture shows the highest initial density (1046 HU) but still requires extended healing 5

Critical Considerations for Osteoporotic Patients

Bone Healing Timeline

• Standard retention periods are insufficient; incomplete ossification of the midpalatal suture persists longer in adults 1
• Posttreatment imaging should confirm adequate suture mineralization before retention removal 1
• The posterior portion of the suture requires the longest healing time to maintain resistance against relapse forces 5

Medication Interactions

Patients on bisphosphonates (alendronate 70 mg weekly or risedronate 35 mg weekly) or denosumab (60 mg subcutaneously every 6 months) for osteoporosis treatment 6 require special consideration:

• These medications reduce bone remodeling, which may affect both expansion success and healing
• Coordinate with the patient's osteoporosis management team before proceeding
• Ensure adequate calcium (1000-1200 mg daily) and vitamin D (800-1000 IU daily) supplementation throughout treatment 6

Recommended Algorithm

For adults with osteoporosis and maxillary transverse deficiency:

1. First-line: MARPE with slow expansion protocol and 3D-printed surgical guides for precise miniscrew placement 1
2. Second-line: RMAE with Haas appliance using limited activation rates 2
3. Last resort: SARPE with extended retention (only if non-surgical methods fail or are contraindicated) 3, 4

Common Pitfalls to Avoid

• Do not use standard rapid expansion protocols in osteoporotic patients—slower activation rates are essential 2, 1
• Do not remove retention prematurely—bone density recovery is significantly delayed compared to healthy bone 5
• Do not assume surgical expansion is automatically necessary—modern MARPE techniques can achieve skeletal expansion even in mature adults with compromised bone 1, 4
• Do not proceed without imaging confirmation of adequate bone healing before retention removal 1