See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/230840936

Rapid maxillary expansion: Effects on palatal area investigated by computed

tomography in growing subjects

Article  in  European Journal of Paediatric Dentistry · September 2012

Source: PubMed

CITATIONS READS

17 404

6 authors, including:

Roberta Lione Chiara Pavoni

University of Rome Tor Vergata University of Rome Tor Vergata
83 PUBLICATIONS   1,166 CITATIONS    65 PUBLICATIONS   650 CITATIONS   

SEE PROFILE SEE PROFILE

Giuseppina Laganà Liliana Ottria

University of Rome Tor Vergata University of Rome Tor Vergata
38 PUBLICATIONS   635 CITATIONS    75 PUBLICATIONS   924 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Superimpositions on the palate View project

The one-page Sleep-Related Breathing Disorder (SRBD) scale extracted from the PSQ View project

All content following this page was uploaded by Paola Cozza on 05 June 2014.

The user has requested enhancement of the downloaded file.

 R. Lione, C. Pavoni, G. Laganà, E. Fanucci*, Introduction
L. Ottria**, P. Cozza
The correlations and connections between the
Department of Orthodontics, University of Rome “Tor Vergata”, stomatognathic system and other apparatuses are
Rome, Italy often the object of investigations. In particular, the
*Department of Radiology correction of skeletal transverse problems of the maxilla
**Department of Odontostomatology can be associated with favourable therapeutic effects
on hearing, swallowing and nasal breathing [Braun,
e-mail: robertalione@yahoo.it 1966; Gray, 1975]. Several authors have evaluated the
effects of Rapid Maxillary Expansion (RME) and they
reported a decrease in nasal resistance, an increase
in respiratory area and an improvement in conductive
Rapid maxillary hearing loss after treatment because the palatal area
is the area where the tongue should be located and
expansion: effects the palatal processes of the maxilla correspond to the
floor of the nasal cavities [Ceylan et al., 1996; Basciftci
on palatal area et al., 2002; Buccheri et al., 2004]. Indeed patients
with constricted maxillary arches tend to posture the
investigated by tongue in a low position and the expansion of the
palatal region allows to reduce low or forward tongue
computed tomography posture [Brodie, 1950]. RME causes improvements in
nasal respiration and in oral posture by increasing the
in growing subjects palatal area and by lowering of the palatal vault [Haas,
1961; Starnbach et al., 1961; Wertz, 1970]. RME was
established as a valid treatment method to correct
transverse maxillary deficiencies, since the effects of
abstract this procedure were substantiated by radiography
[Derichsweiler, 1953; Krebs, 1964]. In the literature a
Aim The aim of this prospective study was to evaluate wide standard radiographic documentation is reported
the effects of rapid maxillary expansion (RME) on and 3D more sophisticated techniques for evaluation
the palatal area as assessed by low-dose CT before of morphological changes in the dentofacial complex
treatment (T0), at the end of active expansion (T1) and have been proposed in the last ten years [Sandikcioglu
after a retention period of 6 months (T2). and Hazar, 1997; da Silva Filho et al., 1995; da Silva
Materials and Methods The study sample Filho et al., 2006; Podesser et al., 2007]. In particular
comprised 17 prepubertal subjects (mean age 11.2 the effects of RME on the palatal vault have been
years) with constricted maxillary arches. Total amount analysed by linear measurements on dental casts,
of expansion was 7 mm in all subjects. Multi-slice low- on posteroanterior cephalograms, and on computed
dose CT scans were taken at T0, T1, and T2. On axial tomography (CT) scanned images [Rungcharassaeng
CT scanned images a circle line corresponding to the et al., 2007; Lione et al., 2008; Ballanti et al., 2009;
palatal area was drawn and the area inside the circle Garib et al., 2005; Habersack et al., 2007; Garret et al.,
registered at all three observation times. The area was 2008; Phatouros et al., 2008]. Currently, the number
measured in mm2. Statistical comparisons were carried of scientific investigations conducted on CT scans is
out with Friedman test with post-hoc tests (P<0.05). limited, while it would add valuable information to
Results The palatal area showed a significant increase existing observations on axial CT scans of the palatal
from T0 to T1 and from T0 to T2 as a consequence of area.
the opening of the midpalatal suture after RME. The aim of this prospective study was to analyse
Conclusion Opening the midpalatal suture by using the changes of the palatal area after RME as assessed
orthopedic forces allowed to extend the area of the by low-dose CT before treatment (T0), at the end of
maxilla. After a 6-months retention period the palatal active expansion (T1) and after a retention period of
area demonstrated a stable increase due to a bone 6 months (T2). The palatal area was studied by using
deposition along the midpalatal suture in both the a diagnostic tool reported in literature to evaluate
anterior and posterior parts of the maxilla. glenoid bone loss [Nofsinger et al., 2010].
This radiographic method of investigation is able
to show the modification of the palatal area after
Keywords Computed tomography; Imaging 3D; treatment by using a standardised circle area that is
Palatal vault; Rapid maxillary expansion. not influenced by tooth position, alveolar and skeletal
morphology.

European Journal of Paediatric Dentistry vol. 13/3-2012 215

Lione R. et al.

Materials and methods

The prospective study sample comprised 17 Caucasian
subjects (7 males and 10 females) with a mean age of
11.2 years (range 8-14 years) who sought orthodontic
treatment at the Department of Orthodontics of the
University of Rome “Tor Vergata”. Selection criteria
were: constricted maxillary arches, and stages in
cervical vertebral maturation as assessed on lateral
cephalograms ranging from CS1 to CS3 (prepubertal)
[Baccetti et al., 2005]. This project was approved by
the Ethical Committee of the University of Rome “Tor
Vergata”, and informed consent was obtained from the
parents of the patients.
Each patient underwent a standardised protocol with
RME in the form of the Butterfly Palatal Expander that fig 1 Axial scans taken before RME (T0), with the circle area
followed the basic design of Haas [Cozza et al., 2001]. recorded.
The expansion screw was activated at 2 turns per day
(0.25 mm per turn) for 14 days, thus reaching the total
amount of screw expansion of 7 mm in all subjects.
Then, the screw was tied off with a ligature wire, and
the expander was kept in place as a passive retainer for
6 months.
Multi-slice low-dose CT scans were taken before
rapid palatal expansion (T0), at the end of the active
expansion phase (T1), and after a retention period of
6 months (T2). The scans were carried out by a single
trained radiographer at the same scanner console
with the primary indication of evaluating the exact
position of displaced intraosseous canines in the
maxilla. All exams were performed at the Department
of Radiology, University of Rome, “Tor Vergata”, with a
CT scanner endowed with a Dentascan reconstruction
program used to study the maxillofacial region (Light-
Speed 16, General Electric Medical System, Milwaukee, fig 2 Axial scans taken after a 6-month retention period (T2),
Winsconsin, USA). This machine is equipped with 16 with the all three circle areas superimposed.
detector rows and has a minimal rotation time of 0.5
s, given a collimation between 0.75 and 1.5 mm with
dose calibration. Subsequent scans were taken with a magnification factor with a specific software (Light-
1.25 mm slice thickness, 0.6 mm interval, 11.25 mm Speed 16, General Electric Medical System, Milwaukee,
table speed/rotation, 100 mA, 13.7 cm FOV, 512x512 Winsconsin, USA). On the enlarged images a circle line
matrix, 0° gantry angle, and following a low dose was drawn passing through the following points.
protocol with 80 KV instead of the standard CT setting 1. The external aspect of the palatal cortical plate of
of 120 KV. the right maxillary first molar.
Each patient was positioned horizontally on the 2. The external aspect of the palatal cortical plate
scanner table with the Camper’s plane perpendicular corresponding to the right maxillary central incisor.
to the ground. The perpendicular light beams of the 3. The external aspect of the palatal cortical plate of
machine were used to standardise the head position the left maxillary first molar.
in the three planes, thus allowing a comparison of the The area inside the circle was registered and measured
images achieved before, during, and after expansion. at all three observation times in square millimeters
During the CT scanning, patients were biting on a piece (mm2). The circle areas were placed by a single trained
of gauze to keep the maxillary and the mandibular teeth operator for the calculation of extension at T0, T1, and
separated, and to avoid the overlapping of dentofacial T2 (Fig. 1, 2). The operator was blinded to the case
structures. being measured.
Standardised axial CT images parallel to the palatal
plane and passing through trifurcation of the right Statistical analysis
upper first molar were acquired and enlarged by 3x A single operator (RL) performed all measurements

216 European Journal of Paediatric Dentistry vol. 13/3-2012

 RME ANALYSED BY by computed tomography

T0 T1 T2 Comparisons of the means

Mean SD Mean SD Mean SD T0 vs. T1 T1 vs. T2 T0 vs. T2

Circle area (mm2) 525.6 125.2 691.3 97.7 721.1 92.7 165.7 * 29.8 ns 195.5 *

ns: not significant; * p<0.005

tabLE 1 Descriptive statistics and statistical comparisons of extension of circle area at T0, T1, and T2 (Friedman test with Tukey’s
post-hoc tests).

at the same scanner console, and repeated all was used to determine the percentage of the perfect
measurements after one month. Systematic and circle occupied by the glenoid creating an anatomic
random errors on the measures repeated on the 17 preoperative description of bone loss [Nofsinger et al.,
subjects at all observations periods were calculated with 2010].
paired t-tests and Dahlberg’s formula [Dahlberg, 1940], Computed Tomography (CT) analysis of RME effects
respectively. No statistically significant differences (P > gives better quality and accuracy of the diagnostic
0.05) were found between the first and the second parameters measured, and it might soon become the
measurements for any of the analysed variables; the routine analysis for patients undergoing such treatment
range for random errors was 0.1 to 0.3 mm2. [Habersack al., 2007; Phatorous et al., 2008]. To our
Friedman test with Tukey’s post-hoc tests was used knowledge, the present investigation is the first attempt
(P<0.05). All statistical computations were performed to use a 3D scanning technique to assess morphologic
with a statistical software (SigmaStat 3.5, Systat palatal changes after expansion therapy by using a
Software Inc., Point Richmond, Ca, USA). The level of standardised circle area that is not influenced by tooth
significance was set at p<0.05. position, alveolar and skeletal anatomy.
The total expansion of the palatal area with an RME
appliance can be divided in skeletal expansion and
Results alveolar bending. The first one is due to the direct
separation of the maxillary halves as a result of the
The midpalatal suture was opened in all subjects. opening of the midpalatal suture, while the alveolar
The circle area showed a significant increase from T0 to bending is an additional expansion at the buccal
T1 (+165.7 mm2,) as a consequence of the opening of alveolar plate [Garret et al., 2008]. At the end of active
the midpalatal suture after RME. A significant increase treatment (T1) the net increase in area was 165.7 mm2.
from T0 to T2 (+195.5 mm2) and lack of statistically This data might suggest that expansion of constricted
significant differences from T1 to T2 (+29.8 mm2), was maxillary arch produces marked increases in the area
observed (Table 1). of the palate and it can be assumed that the marked
increase in the palatal area is a result of the midpalatal
Discussion suture opening in conjunction with alveolar arch
tipping. Moreover using a circle area it was possible to
The purpose of this study was to analyse the demonstrate that RME increased transverse dimension
treatment and post-retention effects of RME on the without reducing the arch perimeter. When the circle
palatal area on axial CT scans. Similar measurements areas obtained at T0, T1, T2 are superimposed on one
have been attempted in previous studies but research point (the external aspect of the palatal cortical plate of
was limited to using 2D X-ray or casts model for the right maxillary first molar), it is pointed out that the
data acquisition [Haas, 1961; Starnbach et al., 1966; orthopedic expansion affected the palatal area in both
Wertz, 1970]. The method used in the present study transverse and sagittal dimensions (Fig.2). This effect
was previously described in literature to evaluate the was due to the opening of the midpalatal suture that
anterior part of the glenoid in anterior glenohumeral is decreasing from the anterior to the posterior part of
instability, based on the typically circular geometry the palate.
of the inferior glenoid. A three-dimensional (3D)- After a 6-month retention period (T2) the palatal
reconstructed computerised tomography en face area resulted stable with an additional value of 29.8
images of the glenoid with "subtraction" of the mm2 during the T1-T2 interval. The appliance was
humeral head was used to overlay a perfect circle maintained in place as a passive retainer for 6 months
that was fit to the glenoid. The anterior aspect of the to allow complete recovery and reorganisation of the
circle was then adjusted to match the true anatomic midpalatal suture and to avoid a relapse of skeletal
contour of the anterior glenoid. This adjusted region effects in both the oral and nasal cavity.

European Journal of Paediatric Dentistry vol. 13/3-2012 217

 Lione R. et al.

› Derichsweiler H. Die Gaumennahtsprengung. Fortschr Kieferorthop

Conclusions 1953;14:5-23.
› Garib DG, Henriques JFC, Janson G, De Freitas MR, Coelho RA. Rapid
› Opening the midpalatal suture by using orthopedic maxillary expansion-tooth tissue-borne versus tooth-borne expanders: a
forces allowed to extend the area of the maxilla (T1) computed tomography evaluation of dentoskeletal effects. Angle Orthod
increasing the transverse dimension and without 2005;75:548-57.
reducing the arch perimeter. › Garret BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS, Taylor GD.
› After a 6-months retention period (T2) the palatal Skeletal effects to the maxilla after rapid maxillary expansion assessed
with cone-beam computed tomography. Am J Orthod Dentofacial Orthop
area demonstrated a stable increase due to bone 2008;134:8 e1-8.e-11.
deposition along the midpalatal suture in both the › Gray LP. Results of 310 cases of rapid maxillary expansion selected for
anterior and posterior parts of the maxilla. medical reasons. J Larnygol Otol 1975;89:601-14.
› Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by
opening the midpalatal suture. Angle Orthod 1961;31:73-90.
References › Habersack K, Karoglan A, Sommer B, Benner KU. High-resolution
multislices computerized tomography with multiplanar and 3-dimensional
reformation imaging in rapid palatal expansion. Am J Orthod Dentofacial
› Baccetti T, Franchi L, McNamara JA. The cervical vertebrae maturation
Orthop 2007;131:776-81.
(CVM) method for the assessment of optimal treatment timing in
› Krebs AA. Midpalatal suture expansion studied by the implant method
dentofacial orthopedics. Sem Orthod 2005;11:119-29.
over a 7-year period. Trans Eur Orthod Soc 1964:131-42.
› Ballanti F, Lione R, Fanucci E, Franchi L, Baccetti T, Cozza P. Immediate
› Lione R, Ballanti F, Franchi L, Baccetti T, Cozza P. Treatment and post-
and post-retention effects of rapid maxillary expansion investigated by
treatment skeletal effects of RME investigated by low-dose TC in growing
computed tomography in growing patients. Angle Orthod 2009;79:24-29.
subjects. Am J Orthod Dentofacial Orthop 2008;134:389-92.
› Basciftci FA, Mutlu N, Karaman AI, Malkoc S. Does the timing and method
› Nofsinger C, Browning B, Burkhart S, Pedowitz R. Objective Preoperative
of rapid maxillary expansion have an effect on the changes in nasal
Measurement of Anterior Glenoid Bone Loss: A Pilot Study of a Computer-
dimensions? Angle Orthod 2002;72:118-23.
Based Method Using Unilateral 3-Dimensional Computed Tomography.
› Braun F. A contribution of the problem of bronchial asthma and extension
Arthroscopy. 2010 Dec 30.
of the palatal suture. Trans Eur Orthod Soc. 1966;42:363.
› Phatouros A, Goonewardene MS. Morphologic changes of the palatal
› Brodie AG. Anatomy and physiology of head and neck musculature. Am J
after rapid maxillary expansion: a 3-dimensional computed tomography
Orthod 1950;36:831-44.
evaluation. Am J Orthod Dentofacial Orthop 2008;134:117-24.
› Buccheri A, Dilella G, Stella R. Rapid palatal expansion and pharyngeal
› Podesser B, Williams S, Crismani AG, Banteleon H-P. Evaluation of
space. Cephalometric evaluation. Prog Orthod 2004;5:160-71.
the effects of rapid maxillary expansion in growing children using
› Ceylan I, Oktay H, Demirci M. The effect of rapid maxillary expansion on computedtomography scanning: a pilot study. Eur J Orthod 2007;29:37-
conductive hearing loss. Angle Orthod 1996;66:301-08. 44.
› Cozza P, Giancotti A, Petrosino A. Rapid palatal expansion in mixed › Rungcharassaeng K, Caruso JM, Kan JYK, Kim J, Taylor G. Factors
dentition using a modified expander: a cephalometric investigation. J affecting buccal bone changes of maxillary posterior teeth after rapid
Clinical Orthod 2001;28:129-34. maxillary expansion. Am J Orthod Dentofacial Orthop 2007;132:428.e1-
› da Silva Filho OG, Lara TS, da Silva HC, Bertoz FA. Post expansion 428.e8.
evaluation of the midpalatal suture in children submitted to rapid palatal › Sandikcioglu M, Hazar S. Skeletal and dental changes after maxillary
expansion: a CT study. J Clinical Pediatric Dentistry 2006;31:142-8. expansion in the mixed dentition. Am J Orthod Dentofacial Orthop
› da Silva Filho OG, Montes LA, Torelly LF. Rapid maxillary expansion in 1997;111:321-7.
the deciduous and mixed dentition evaluated through posteroanterior › Starnbach HK, Bayne D, Cleall JF, Subtelny DJ. Facioskeletal and dental
cephalometric analysis. Am J Orthod Dentofacial Orthop 1995;107:268- changes resulting from rapid maxillary expansion. Angle Orthod
275. 1966;36:152-64.
› Dahlberg G. Statistical methods for medical and biological students. New › Wertz RA. Skeletal and dental changes accompanying rapid mid-palatal
York: Interscience publications 1940. suture opening. Am J Orthod 1970;58:41-66.

218 European Journal of Paediatric Dentistry vol. 13/3-2012

View publication stats