## 5 Discussion
Therefore, a 1-24\({}^{\circ}\) increase in molar inclination is inevitable, probably because of alveolar bending and/or tipping of the posterior teeth [21]. [PERSON] et al. [22] showed this in a study of 33 adults aged between 23 and 33 years, where 90% of the patients had successful palatal widening without a surgically assisted rapid palatal expander (SARPE) and no dental side effects [22]. [PERSON] et al. [23] conducted a study on 48 late-adolescent patients divided into two groups according to the type of expander: MSE group (\(n=24\), age = 19.2 \(\pm\) 5.9 years) and bone-borne expanders group (\(n=24\), age = 18.1 \(\pm\) 4.5 years). CBCT scans were taken before treatment and 3 months after expansion. Transverse skeletal and dental expansion, alveolar inclination, tooth axis, buccal alveolar bone height, thickness, dehiscence, and fenestration were evaluated on the maxillary first molar. They concluded that the incorporation of teeth into bone-borne expanders resulted in an increase in the severity of side effects. For patients in late adolescence, tissue bone-borne expanders offer comparable skeletal effects to tooth bone-borne expanders, with fewer dentoalveolar side effects [23]. In a randomized control trial regarding the use of bone-borne expansion in the adolescent population, [PERSON] et al. [24] showed an increased extent of skeletal changes in the range of 1.5-2.8 times that of tooth-borne expansion and did not result in any dental side effects [24]. In another study of late-adolescent patients, [PERSON] et al. showed that bone-borne expanders produced greater transverse skeletal expansion than tooth-borne Hyrax expanders. In the bone-borne expander group, there was less alveolar bending, less dental tipping, and less vertical alveolar bone loss at the first premolar [19]. Regarding the limitations of MARPE devices, [PERSON] et al. reported that MARPE therapy requires a longer activation time and twice the force for the rupture of the medial palatine suture compared to SARPE [25]. Other disadvantages of MARPE: it may cause temporary inflammation of the palatal mucosa [26], difficulty in hygiene around micro-implants, and risk of infection [1]. Regarding other limitations, [PERSON] et al. named the possibility of failure to separate the suture due to the resistance of the craniofacial structures [27] and when a patient presents a narrow and deep palate because the proper position of some MARPE devices cannot be achieved, since it should be placed close to the palatal mucosa [28]. In such cases, surgically assisted rapid palatal expanders (SARPE) is often suggested to these patients. This surgical procedure increases expansion predictability and success and reduces its side effects. One of the available SARPE techniques consists of a LeFort I osteotomy, associated with surgical rupture of the mid-palatal suture, which decreases mechanical resistance to the lateral forces that will be applied by Hyrax expanders, usually anchored to the first molars and first premolars. However, despite its benefits, SARPE requires hospitalization and increases the biological and financial costs of the treatment [16]. To minimize the surgical procedure and reduce postoperative discomfort, other techniques may be recommended. Cortico-puncture is a method that increases the expression of cytokines and chemokines responsible for stimulating the differentiation of osteoclasts in bone remodeling and thus increasing the rate of tooth movement by up to 62% [23]. Our study demonstrates the use of CP therapy as a surgical method for accelerating bone remodeling to complement the MARPE technique to facilitate suture split. In their study on maxillary expansion in rabbits, [PERSON] et al. suggested that greater skeletal ex pansions may be possible when combined with surgical methods such as cortico-puncture to promote regional acceleratory phenomenon (RAP), stimulating bone remodeling, and reducing bone volume and density [29]. In animal studies, [PERSON] et al.