Original Article

Effects of rapid maxillary expansion on upper airway volume:

A three-dimensional cone-beam computed tomography study
Yousef Abdallaa; Louise Brownb; Liselotte Sonnesenc

ABSTRACT
Objective: To compare changes in pharyngeal airway volume and minimal cross-sectional area
(MCA) between patients undergoing rapid maxillary expansion (RME) and a matched control group
and to identify markers for predicting airway changes using cone-beam computed tomography
(CBCT).
Materials and Methods: Pre- and posttreatment CBCT scans were selected of children who had
RME (14 girls and 12 boys; mean age, 12.4 years) along with scans of a control group (matched for
chronological age, skeletal age, gender, mandibular inclination) who underwent orthodontic
treatment for minor malocclusions without RME. Changes in airway volume and MCA were
evaluated using a standardized, previously validated method and analyzed by a mixed-effects
linear regression model.
Results: Upper airway volume and MCA increased significantly over time for both the RME and
matched control groups (P , .01 and P ¼ .05, respectively). Although the RME group showed a
greater increase when compared with the matched controls, this difference was not statistically
significant. A reduced skeletal age before treatment was a significant marker for a positive effect on
the upper airway volume and MCA changes (P , .01).
Conclusions: Tooth-borne RME is not associated with a significant change in upper airway volume
or MCA in children when compared with controls. The younger the skeletal age before treatment,
the more positive the effect on the upper airway changes. The results may prove valuable,
especially in RME of young children. (Angle Orthod. 2019;89:917–923.)
KEY WORDS: Maxillary expansion; Upper airway volume; Children; CBCT

INTRODUCTION
The dentofacial changes that develop as a result of
upper airway constriction have been well documented
a
PhD student, Section of Orthodontics, Department of in the literature, and early diagnosis and treatment are
Odontology, Faculty of Health and Medical Sciences, University desirable to encourage normal craniofacial develop-
of Copenhagen, Copenhagen, Denmark, and Lecturer in ment.1 More recently, the association between upper
Orthodontics, College of Medicine and Dentistry, James Cook
airway morphology, sleep-disordered breathing, and
University, Cairns, Australia.
b
Dento-Maxillofacial Radiologist, Melbourne and Honorary obstructive sleep apnea (OSA) has been studied, and
Associate Professor, School of Dentistry, University of Queens- there is a general agreement that early management of
land, Brisbane, Australia. these conditions may lead to better long-term medical
c
Professor and Director of Postgraduate Program, Section of and dental outcomes for patients.2
Orthodontics, Department of Odontology, Faculty of Health and
Medical Sciences, University of Copenhagen, Copenhagen,
Rapid maxillary expansion (RME) is a commonly
Denmark. used orthodontic treatment to correct transverse dental
Corresponding author: Dr Liselotte Sonnesen, Section of and skeletal discrepancies while providing an increase
Orthodontics, Department of Odontology, Faculty of Health and in arch width to resolve mild to moderate crowding.3
Medical Sciences, University of Copenhagen, 20 Nørre Alle, DK- Using an orthodontic appliance, force is exerted
2200 Copenhagen N, Denmark
(e-mail: alson@sund.ku.dk) laterally against the posterior teeth or palatal mucosa,
which in turn places force on the midpalatal suture. As
Accepted: February 2019. Submitted: October 2018.
Published Online: April 3, 2019 the suture is usually patent in children and adoles-
Ó 2019 by The EH Angle Education and Research Foundation, cents, the application of force perpendicular to it may
Inc. lead to transverse maxillary growth.4

DOI: 10.2319/101218-738.1 917 Angle Orthodontist, Vol 89, No 6, 2019

918 ABDALLA, BROWN, SONNESEN

Although the primary aim of RME is to exert force expansion screw on a tooth-borne Hyrax-type expand-
on the maxilla, studies have shown that the skeletal er 0.25 mm per day for a minimum of 2 weeks. There
effects are much more extensive, with displacement was a retention period of 6 months, after which some of
occurring in all bones articulating with the maxilla, the RME patients continued with fixed appliances. The
except for the sphenoid bone, as well as the airway.5 matched control group underwent nonextraction ortho-
Cistulli et al.6 investigated the effects of RME in a dontic treatment with fixed appliances only (no RME)
sample of 10 patients with mild to moderate OSA. for minor malocclusions.
Nine of these patients reported an improvement in The CBCT scans were obtained from a database of
snoring and daytime sleepiness, and all patients 784 orthodontic patients who attended a private
demonstrated a reduction in the Respiratory Distress practice in Victoria, Australia, for orthodontic treat-
Index, which returned to normal in seven patients. ment between 2006 and 2012. Before they were
The authors concluded that RME may be a useful entered into the database, all images were anony-
treatment alternative for selected patients with mized. Sex, age, morphological occlusion according
OSA.6 to Angle’s classification, and type of orthodontic
Understanding the effects of RME on the upper treatment were also obtained from the database.
airway in three dimensions has historically been The inclusion criteria were (1) RME treatment with a
problematic. Acoustic rhinometry has been used; tooth-borne Hyrax expander due to a unilateral or
however, this technique is limited to the nasal bilateral crossbite, followed by fixed appliances; (2) a
passages. 7,8 More recently, the use of medical minimum increase of 3 mm in the intermolar width
computed tomography has been described; however, between pre- and posttreatment scans, which would
the limitations of this technique are that the radiation result in a minimum expected orthopedic change in
dose is relatively high and patients must be in the the maxilla of 1.5 mm20; (3) pretreatment and progress
supine position.9,10 It has been shown that placement CBCT scans with complete imaging of the cranial
in these positions affects the volume of the air- base, maxilla, mandible, and first four cervical
ways.11–14 vertebrae and associated airways; (4) children be-
Cone-beam computed tomography (CBCT) has tween 8 and 15 years of age; and (5) biting in habitual
been shown to be an accurate and reliable method of intercuspal position with an Angle Class I molar
assessing the upper airway in the upright position15 and relationship. The exclusion criteria were (1) previous
is able to define the boundaries between the airway orthodontic treatment, (2) previous adenotonsillec-
spaces and soft tissues accurately in both adults and tomy, (3) known syndromic conditions, (4) movement
children with easily identifiable landmarks and negligi- artifacts, (5) swallowing during scan acquisition, and
ble magnification.16 A recent systematic review of (6) treatment plan requiring orthodontic extractions.
previous CBCT studies investigating the changes in Once inclusion and exclusion criteria had been
airway before and after treatment with RME found applied, the final sample consisted of 26 patients.
conflicting results and a lack of homogeneity among The power of the sample size was calculated, and it
the measurement protocols used.17 Anandarajah18 was determined that 21 subjects would be needed to
proposed and validated a standardized method of achieve a power of 80% (a ¼ .05).
upper airway assessment using CBCT and has used A control group of 26 Angle Class I patients who had
this technique to demonstrate an association between nonextraction treatment with fixed appliances only was
maxillary and mandibular width and airway volume in randomly selected to match the RME group for
healthy untreated children.19 chronological age (mean, 12 years, 4 months 6 2
The aims of this study were (1) to compare changes years, 4 months), skeletal age using the Cervical
in pharyngeal airway volume and minimal cross- Vertebral Maturation index according to Baccetti et al.21
sectional area (MCA) in an RME group with that of a (cervical vertebral maturation: stage 1 ¼ 3, 2 ¼ 8, 3 ¼ 6,
4 ¼ 7, 5 ¼ 2), gender (male ¼ 12, female ¼ 14), and time
control group matched in age, skeletal age, gender,
interval between the pretreatment and progress scans
and mandibular inclination using a validated method of
(2 years 6 11 months). Patients were also matched for
airway volume measurement18 and (2) to identify
the mandibular inclination according to Björk22 (nasion-
pretreatment markers for predicting airway change in
sella line/mandibular line 338 6 68), which was
the two groups combined.
determined using digital tracings of lateral cephalo-
metric radiographs generated from the CBCT scans
MATERIALS AND METHODS
(Total Interactive Orthodontic Planning System (TIOPS
This was a retrospective study involving two groups: 4, Roskilde, Denmark). The study was approved by the
an RME group and a pair-matched control group. The Danish Data Protection Board (ref. SUND-2015-57-
expansion protocol for the RME group was to turn the 0121).

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UPPER AIRWAY CHANGES AFTER RME 919

validated protocol,18 which is briefly outlined below

and illustrated in Figure 1.
To standardize the measurements, the skull was
oriented in all three planes according to the following
lines: coronal plane (horizontal line through orbitale),
sagittal plane (Frankfort horizontal), and axial plane
(Crista galli to basion). The airway margins are
illustrated in Figure 1 and were outlined on a sagittal
slice representing the midsagittal plane. The margins
were superior (palatal plane), inferior (line passing from
the antero-superior edge of C4 to menton), anterior
(line passing from the soft palate to menton), posterior
(posterior wall of the pharynx), and lateral (respective
pharyngeal walls). The process of airway segmentation
was systematized as follows:
 The ‘‘seed point’’ was defined as a virtual marker for
the region of interest demarcation and was placed
centrally in the airway region immediately posterior to
the soft palate to facilitate automated segmentation of
the airway based on gray-scale values.
 The most appropriate threshold value for each patient

was determined automatically by the software. The

sagittal view was then enlarged as much as possible
while ensuring visualization of all previously deter-
Figure 1. Illustration of margins for delineation of upper airway. mined margins. The threshold was manually adjusted
Superior: line passing from the palatal plane (ANS – PNS) extending if necessary for each data set (operator-adjusted
to the posterior wall of the pharynx. Inferior: line passing from the threshold) until the airway volume adequately depict-
anterosuperior edge of the fourth cervical vertebra (C4) to menton ed the airway–soft tissue interface. Coronal and
(Me). Anterior: line passing from soft palate to menton (Me).
transverse views were then evaluated to ensure the
Posterior: posterior wall of pharynx. Lateral: respective pharyngeal
walls.18 manually adjusted threshold value was correct and
there was no extension of the airway segmentation
Scan Protocol into the soft tissues.

All images were acquired using an iCAT Next The MCA was calculated by setting the upper and
lower limits within the previously defined margins,
Generation CBCT machine (Imaging Sciences Inter-
which included both anterior and posterior margins of
national, Hatfield, Pa) by the same operator. The
the airway. This was to ensure that a partial section
following parameters were used: 120 Kv, 5 mA, 0.4-
created by the difference in airway boundary for
mm voxel resolution, 8.9-second scan time, and 13-cm
volume and the plane for area calculation was not
(height) 3 16-cm (diameter) scan volume. Patients
used to determine MCA. The software automatically
were seated and restrained with a headrest and head
calculated the MCA (mm2) within the defined margins.
strap but no chin rest to allow the Frankfort horizontal Both measurements were carried out at the beginning
plane to be positioned parallel with the floor. Patients (T0) and the end of active treatment (T1).
were instructed to occlude in the intercuspal position,
relax their lips and tongue, breathe gently, and not Assessment of Transverse Effects of RME
swallow or move during acquisition.
Maxillary and mandibular width at T0 and T1 was
Image Preparation and Airway Assessment assessed for the RME group using posteroanterior
cephalometric radiographs. These were generated
The Digital Imaging and Communications in Medi- automatically by the software at zero magnification
cine (DICOM) data were processed using Dolphin with the scans in their previously standardized position
Imaging Software (version 11.5; Dolphin Imaging and and then compared with the matched control group to
Management Solutions, Chatsworth, Calif). Images evaluate the skeletal treatment changes achieved with
were analyzed under the same lighting conditions the RME appliance, according to the method described
and by the same investigator using a previously by Yoon et al.23 (Figure 2). The intermolar width was

Angle Orthodontist, Vol 89, No 6, 2019

920 ABDALLA, BROWN, SONNESEN

Figure 2. Illustrations of transverse skeletal and dental measurements. (A) posteroanterior cephalometric reference points (Mx: intersection of the
lateral contour of the maxillary alveolar process and the lower contour of the maxillozygomatic process of the maxilla; Go: the most lateral point on
the angle of the mandible) and lines (dotted) measuring the maxillary width (Mx-Mx) and mandibular width (Go-Go).23 (B) Intermolar width
measurement from the most palatal aspects of the upper first molars at the level of the cementoenamel junction.24

measured on the CBCT scans from the most palatal pairs. A backward, stepwise regression model (P ,
aspect of the upper first molars at the level of the .05) using bootstrap aggregation with replacement and
cementoenamel junction, as described by Adkins et 1000 repetitions determined whether any of the
al.24 (Figure 2). variables measured at T0 (Table 1) were effective
markers for predicting the degree of change in airway
Reliability volume and MCA. Statistical analysis was carried out
Twenty randomly selected patient measurements using Stata version 15 (StataCorp LLC, College
were repeated after 2 weeks to assess the method Station, Tex).
error and reliability of the upper airway measures, the
transverse cephalometric measurements, and the RESULTS
mandibular inclination. No systematic error was found There were no significant differences in the skeletal
when tested by a t-test. The method error according to and airway measurements between the RME and
Dahlberg’s formula25 ranged between 0.2% and 1.9%, matched control group at T0. However, the maxillary
and the reliability according to Houston26 was 1 for all intermolar width was significantly smaller in the RME
measurements. group when compared with the matched control group
(29.2 mm and 31.7 mm, respectively; P , .001).
Statistical Analysis Both groups showed a significant increase in the
Both the RME and control group data sets were maxillary, mandibular, and molar widths as well as
normally distributed when tested by a Shapiro-Wilks airway volume and MCA between T0 and T1 (Table 1).
test. The dentofacial and airway differences between In the RME group, the increase in the maxillary and
the two groups at T0 were evaluated by a paired t-test. intermolar width was significantly greater compared
The intra- and intergroup changes in the dentofacial with the controls (P ¼ .05 and P , .001, respectively).
and airway measurements between T0 and T1 were No significant difference in the increase in the upper
evaluated separately using a linear mixed-effects airway volume and MCA was found in the RME group
model, which allowed for the longitudinal and nested when compared with the controls (Table 1).
structure of the data. The fixed effects part of the Skeletal age was the only significant pretreatment
models included the dependent variable volume and marker for prediction of airway change during treat-
MCA and independent variables group and time as ment. Patients with a younger skeletal age showed the
well as their interaction. The random effects part of the greatest increase in airway volume and MCA (P ¼ .01
model included the individual participants nested in and P ¼ .02, respectively; Table 2).

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UPPER AIRWAY CHANGES AFTER RME 921

Table 1. Changes Between T0 and T1 in the RME and Control Groups

T0 T1 P Value 95% Confidence Interval
Volume, mm 3

Control group 12216.05 15794.43 .006 13,258.24 to 18,330.62

RME group 12873.73 17460.92 ,.001 15,028.06 to 19,893.78
RME effect þ1008.81 .56 2401.10 to 4418.73
MCA, mm2
Control group 125.97 169.54 .020 131.89 to 207.18
RME group 126.53 164.69 .018 132.97 to 196.40
RME effect 5.41 .83 56.02 to 45.19
Maxillary width, mm
Control group 58.90 60.17 .004 59.31 to 61.03
RME group 58.78 61.70 ,.001 60.84 to 62.57
RME effect þ1.65 .005 0.50 to 2.80
Maxillary intermolar width, mm
Control group 31.74 32.62 .001 32.28 to 33.75
RME group 29.23 33.83 ,.001 33.14 to 34.52
RME effect þ3.72 ,.001 2.33 to 4.31
Mandibular width, mm
Control group 86.18 89.49 ,.001 88.61 to 90.38
RME group 86.50 89.31 ,.001 88.50 to 90.12
RME effect -0.50 .41 1.67 to 0.69

DISCUSSION in disagreement with some previous studies29,32 but not

others.30,33 The increase in airway volume and MCA
The present study investigated the airway volume
over time in both groups was likely due to growth. A
and MCA in children who had tooth-borne RME
CBCT airway growth study of 1300 patients found that
treatment followed by fixed appliances compared with there was a consistent increase in upper airway volume
a nonextraction fixed appliance control group, evaluat- from age 6–20 years.34
ed by standardized three-dimensional analysis of Despite the significant increase in the maxillary width
CBCT scans. 18 Gender, age, skeletal age, and in the RME group, no significant increase in the airway
mandibular inclination were also controlled for, since volume or MCA was found in the RME group when
these have previously been shown to be closely compared with the controls in this study. This was
associated with upper airway dimensions.19,27,28 consistent with most previous studies, which have also
In the present study, both groups showed a significant found that, although RME significantly increased the
increase in the dental and skeletal maxillary width, volume of the nasal airway, there was no effect on the
which was in agreement with previous studies.29–31 pharyngeal airway volume.29,30,32,35,36 However, one
There was also a significant increase in airway volume study did find that RME increased pharyngeal airway
and MCA in both groups between T0 and T1, which was volume.37 There are conflicting findings from previous

Table 2. Backward Stepwise Regression Evaluating the Effect of Pretreatment Markers on Airway Volume and MCA
P Value Regression Coefficient 95% Confidence Interval
Volume, mm 3

Mandibular inclination .97 Removed from model

Mandibular width .94 Removed from model
Maxillary width .43 Removed from model
Intermolar width .42 Removed from model
Gender .10 Removed from model
Age .07 Removed from model
Skeletal age .01 3204.66 5657.78 to 751.60
MCA, mm2
Mandibular inclination .98 Removed from model
Mandibular width .95 Removed from model
Maxillary width .71 Removed from model
Inter-molar width .58 Removed from model
Gender .08 Removed from model
Age .06 Removed from model
Skeletal age .02 48.95 89.68 to 8.22

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922 ABDALLA, BROWN, SONNESEN

studies on the effects of RME on MCA, with some 3. McNamara JA. Early intervention in the transverse dimen-
studies finding no effect33,35 and another finding a sion: is it worth the effort? Am J Orthod Dentofacial Orthop.
positive effect32; however, the latter study did not 2002;121:572–574.
4. Is eri H, Tekkaya AE, Öztan Ö, Bilgic S. Biomechanical
compare to a control group. Studies in which minis-
effects of rapid maxillary expansion on the craniofacial
crew-assisted RME was applied have also shown no skeleton, studied by the finite element method. Eur J Orthod.
significant effect on the pharyngeal airway dimen- 1998;20:347–356.
sions38 despite having a considerable skeletal effect.39 5. Bishara SE, Staley RN. Maxillary expansion: clinical
An explanation as to why both tooth-borne and implications. Am J Orthod Dentofacial Orthop. 1987;91:3–
miniscrew-assisted RME had no effect on the pharyn- 14.
geal airway may be the compensatory mechanism of 6. Cistulli PA, Palmisano RG, Poole MD. Treatment of
obstructive sleep apnea syndrome by rapid maxillary
the head posture due to obstruction of the nasal and/or
expansion. Sleep. 1998;21:831–835.
the pharyngeal airway.40 In response to a reduced
7. Doruk C, Sökücü O, Sezer H, Canbay EI. Evaluation of nasal
airway volume, there is an increase in the craniocer- airway resistance during rapid maxillary expansion using
vical angle in order to maintain an adequate airway acoustic rhinometry. Eur J Orthod. 2004;26:397–401.
volume.27 It is therefore possible that RME increases 8. Compadretti GC, Tasca I, Alessandri-Bonetti G, Peri S,
the airway volume and MCA; however, there is also a D’Addario A. Acoustic rhinometric measurements in children
corresponding reduction in the compensatory head undergoing rapid maxillary expansion. Int J Pediatr Otorhi-
posture leading to no overall significant net gain in nolaryngol. 2006;70:27–34.
9. Doruk C, S ökücü O, Biçakçi AA, Yilmaz U, Tas F.
airway volume and MCA.
Comparison of nasal volume changes during rapid maxillary
No association between mandibular inclination and expansion using acoustic rhinometry and computed tomog-
change in airway volume or MCA was found, which raphy. Eur J Orthod. 2007;29:251–255.
was consistent with findings from another CBCT 10. Garib DG, Henriques JFC, Janson G, Freitas MR, Coelho
study. 41 The fact that skeletal age, rather than RA. Rapid maxillary expansion—tooth tissue-borne versus
chronological age, was found to be a predictive marker tooth-borne expanders: a computed tomography evaluation
for the amount of airway change in the present study of dentoskeletal effects. Angle Orthod. 2005;75:548–557.
may be explained by the significant increase in the 11. Martin SE, Mathur R, Marshall I, Douglas NJ. The effect of
age, sex, obesity and posture on upper airway size. Eur
airway volume during the pubertal growth spurt.42
Respir J. 1997;10:2087–2090.
Growth studies have shown that skeletal age is more 12. Neill AM, Angus SM, Sajkov D, McEvoy RD. Effects of sleep
closely associated with the pubertal growth spurt than posture on upper airway stability in patients with obstructive
chronological age.43 sleep apnea. Am J Respir Crit Care Med. 1997;155:199–
204.
CONCLUSIONS 13. Yildirim N, Fitzpatrick MF, Whyte KF, Jalleh R, Wightman
AJ, Douglas NJ. The effect of posture on upper airway
 Despite increasing intermolar and maxillary widths, dimensions in normal subjects and in patients with the sleep
the tooth-borne rapid maxillary expander is not apnea/hypopnea syndrome. Am Rev Respir Dis. 1991;144:
associated with a significant change in upper 845–847.
pharyngeal airway volume or minimum cross-sec- 14. Jan MA, Marshall I, Douglas NJ. Effect of posture on upper
tional area when used in children. airway dimensions in normal human. Am J Respir Crit Care
 Skeletal age was found to be a predictive marker for Med. 1994;149:145–148.
15. Guijarro-Martinez R, Swennen GRJ. Cone-beam computer-
airway changes.
ized tomography imaging and analysis of the upper airway: a
 The results may prove valuable, especially in systematic review of the literature. Int J Oral Maxillofac Surg.
understanding the broader effects of RME in young 2011;40:1227–1237.
children. 16. Weissheimer A, de Menezes LM, Sameshima GT, Enciso R,
Pham J, Grauer D. Imaging software accuracy for 3-
dimensional analysis of the upper airway. Am J Orthod
ACKNOWLEDGMENTS Dentofacial Orthop. 2012;142:801–813.
The authors wish to thank Dr Simon Freezer and Dr Paul 17. Di Carlo G, Saccucci M, Ierardo G, et al. Rapid maxillary
Bucholtz for providing the data used in this study and Professor expansion and upper airway morphology: a systematic
Adrian Esterman, Professor of Biostatistics, for statistical advice. review on the role of cone beam computed tomography.
BioMed Res Int. 2017;2017:5460429.
18. Anandarajah S, Abdalla Y, Dudhia R, Sonnesen L. Proposal
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