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Three-dimensional analysis of effects of rapid maxillary expansion on facial

sutures and bones: A systematic review

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DOI: 10.2319/020413-103.1 · Source: PubMed

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 Systematic Review Article

Three-dimensional analysis of effects of rapid maxillary expansion on facial

sutures and bones
A systematic review
Farhan Bazargania; Ingalill Feldmannb; Lars Bondemarkc

ABSTRACT
Objective: To evaluate the evidence on three-dimensional immediate effects of rapid maxillary
expansion (RME) treatment on growing patients as assessed by computed tomography/cone
beam computed tomography (CT/CBCT) imaging.
Materials and Methods: The published literature was searched through the PubMed, Embase, and
Cochrane Library electronic databases from January 1966 to December 2012. The inclusion criteria
consisted of randomized controlled trials, prospective controlled studies, and prospective case-
series. Two reviewers extracted the data independently and assessed the quality of the studies.
Results: The search strategy resulted in 73 abstracts or full-text articles, of which 10 met the inclusion
criteria. When treating posterior crossbites with a RME device, the existing evidence points out that the
midpalatal suture opening is around 20%–50% of the total screw expansion. There seems to be no
consistent evidence on whether the midpalatal sutural opening is parallel or triangular. The effect on the
nasal cavity dimensions after RME seems to be apparent and indicates an enlargement between 17%
and 33% of the total screw expansion. Circummaxillary sutures, particularly the zygomaticomaxillary
and frontomaxillary sutures and also spheno-occipital synchondrosis, appear to be affected by the
maxillary expansion. Overall, however, the changes were small and the evidence not conclusive.
Conclusions: CT imaging proved to be a useful tool for assessment of treatment effects in all three
dimensions. The majority of the articles were judged to be of low quality, and therefore, no evidence-based
conclusions could to be drawn from these studies. (Angle Orthod. 2013;83:1074–1082.)
KEY WORDS: Rapid maxillary expansion; Skeletal changes; Rapid palatal expansion; 3D imaging;
Systematic review

INTRODUCTION treatment of choice.1 Various appliances and treatment

protocols have been developed and the most common
When a skeletal constricted maxillary arch is diag-
is rapid maxillary expansion (RME). The first use of
nosed in adolescents, orthopedic skeletal expansion
RME was described by Angell2 in 1860. Because RME
involving separation of the midpalatal suture is the
treatment exerts forces of 15–50 N on the maxilla and
a
Senior Consultant, Department of Orthodontics, Postgradu- paramaxillary structures, changes in other skeletal
ate Dental Education Center, Örebro, Sweden. structures beside the maxilla are possible.1 Thus,
b
Senior Consultant, Orthodontic Clinic, Public Dental Service, widening of the nasal cavity and reformation of the
Gävleborg County Council and Centre for Research and maxillary sinus3–8 and changes in circumaxillary su-
Development, Uppsala University/Gävleborg County Council,
tures9,10 and even the sphenoid bone of the cranial base
Gävle, Sweden.
c
Professor and Chair, Department of Orthodontics, Faculty of have been reported after RME treatment.11
Odontology, Malmö University, Malmö, Sweden. Previous investigations of the effects of the RME
Corresponding author: Dr Farhan Bazargani, Senior Consul- treatment have been carried out through two-dimen-
tant, Department of Orthodontics, Postgraduate Dental Educa- sional radiographic examination, which has its limita-
tion Center, PO Box 1126, SE 701 11 Örebro, Sweden
(e-mail: farhan.bazargani@orebroll.se) tions and does not allow an accurate assessment of
the structures involved in all three dimensions without
Accepted: April 2013. Submitted: February 2013.
Published Online: June 7, 2013
structure overlap. Computed tomography (CT) and
G 2013 by The EH Angle Education and Research Foundation, cone beam computed tomography (CBCT) provide a
Inc. scanning technique of much greater resolution and

Angle Orthodontist, Vol 83, No 6, 2013 1074 DOI: 10.2319/020413-103.1

3D ANALYSIS OF EFFECTS OF RME 1075

allow the investigator to obtain three-dimensional (3D) Table 1. Criteria for Quality Grading of Selected Studies
measurement of treatment-related bony structural High value of evidence (All criteria should be met)
changes with minimal image distortion.12,13 The use Randomized clinical trial or a prospective study with a well-defined
of 3D imaging is recommended in orthodontics for control group
several purposes, such as assessing the positions of Sufficient sample size
Defined sample selection description
impacted teeth and evaluating bone grafts in cleft Defined diagnosis and endpoints
regions and RME effects on nasomaxillary struc- Valid outcome measures
tures.14 Although there are several studies investigat- Method error analysis performed
ing 3D effects of RME, there is no consensus in the Blinded measurements performed
literature regarding these effects and a lack of Medium value of evidence (All criteria should be met)
systematic reviews of the published data is apparent. Prospective study or a retrospective study with a well-defined
The basis for evidence-based health care is system- control group
Sufficient sample size
atic reviews. These are compilations from all available
Defined diagnosis and endpoints
scientific evidence for a certain question/problem Defined outcome measures
concerning the benefits or risks of different methods of
Low value of evidence (One or more of the conditions below)
diagnosis, prevention, or treatment. As it is almost
Unclear diagnosis and endpoints and outcome measures
impossible for the clinician to profit by all information Unclear outcome measures
available, systematic reviews are excellent tools to Poorly defined patient material
provide comprehensive summaries on evidence of a Large attrition
certain scientific field. Therefore, the purpose of this
systematic review is to evaluate the evidence on
abstract did not provide sufficient information. The final
immediate 3D effects of the RME treatment assessed
selection was independently performed by two of the
by CT or CBCT imaging in growing patients.
authors. Any discrepancies were solved through
discussion until consensus was accomplished. The
MATERIALS AND METHODS
reference lists of the retrieved articles were also
Search Strategy searched manually for additional relevant publications
that may have been missed in the search.
A literature survey was conducted to identify all
studies that examined the effect of RME on dentoal-
Data Analysis
veolar and/or skeletal structures measured on com-
puted tomography. PubMed, Embase, and Cochrane The following data were extracted: author and year
Library databases from January 1966 to December of publication, study design, participants/dropouts,
2012 were applied, and the MeSH terms used in this intervention, method of outcome measure, imaging
literature search were ‘‘palatal expansion technique’’ parameters, outcome, and conclusions. In addition, to
and ‘‘tomography, x-ray computed.’’ The computerized document the methodologic soundness of each article,
search was accomplished with the assistance of a a quality evaluation was performed. The following
senior health sciences librarian. variables were evaluated: study design, sample size,
selection description, defined diagnosis and endpoints,
Selection Criteria valid outcome measures, method error analysis, and
blinding in measurements.
Randomized controlled trials, prospective controlled
Each article was graded as high, medium, or low
studies, and prospective case-series were considered
according to predetermined criteria (Table 1). Two
eligible to be included in this review. The studies had to
authors performed the data extraction and indepen-
be written in English and had to concern human subjects
dently graded the articles without blinding. Based on the
up to 18 years of age, with quantitative data on the
evaluated studies, the grading and the final level of
immediate effect of RME assessed by CBCT or CT.
evidence was judged according to the protocols of the
Studies considering surgical treatment and/or surgery in
Centre for Reviewers and Disseminations in York, UK
combination with RME and papers regarding syndromic
and The Swedish Council on Technology Assessment
or medically compromised patients were excluded.
in Health Care.15,16
Eligibility of potential studies was determined by
reading the title and abstract of each article identified
RESULTS
by the search, and then full text articles from the
selected abstracts/titles were retrieved. A study was The search strategy resulted in 73 articles. All
ordered in full text if at least one of the two reviewers of these articles were analyzed according to the
considered it to be potentially relevant or if the title and inclusion/exclusion criteria, and 10 articles were qual-

Angle Orthodontist, Vol 83, No 6, 2013

1076 BAZARGANI, FELDMANN, BONDEMARK

Figure 1. Search-flow diagram adopted from the PRISMA statement.17

ified for the final analysis. The review details and Midpalatal Suture
selection process are given in Figure 1 as described in
Measurements of changes in midpalatal suture
the PRISMA statement.17 The interexaminer agreement
width during RME were presented in six stud-
(kappa statistics) for inclusion of studies was 0.90.
ies,9,12,14,20–22 and five of them presented data for both
Summarized data of the 10 studies are presented in
the anterior and posterior region. The mean expansion
Table 2. Two studies were randomized controlled trials
changes in the midpalatal suture in the posterior region
and eight were prospective case-series. In the
ranged from 1.6 to 4.33 mm, which corresponded to
included studies, the age of the participants ranged
22%–53% of the total screw expansion. Mean expan-
between 6 and 14.5 years. A number of the retrieved
sion changes in the anterior midpalatal suture ranged
studies had the same patient material but with different
from 1.52 to 4.33 mm, corresponding also to 22%–
aims, so no results have been duplicated in this review.
53% of total screw expansion. The reviewed articles
had different endpoints and slightly different reference
Endpoints
points when measuring the midpalatal suture opening,
Three studies9,11,18 defined endpoints as when the which makes comparisons difficult. Three studies12,14,20
maxillary lingual cusp of the permanent first molar came concluded that the suture opened in a triangular
into contact with the mandibular buccal cusp of the pattern with the largest opening at the anterior part.
permanent first molar. Four studies defined endpoints as One study22 reported that the midpalatal suture
when the screw expansion reached 7 mm,12,19–21 and opening was parallel, while Podesser et al.21 reported
one study14 had the endpoint after 8 mm of screw that the suture opening was larger anteriorly in some
expansion. Two studies13,22 did not define any endpoints. individuals and larger posteriorly in others.

Skeletal Changes Nasal Cavity

In reference to the skeletal changes, the majority of the Changes in the width of the nasal cavity were
measurements conducted in the reviewed studies were investigated in three studies at the level of the first
linear and carried out either on coronal or axial 2D slices. molars. The nasal width was expanded by 1.2 mm,21

Angle Orthodontist, Vol 83, No 6, 2013

3D ANALYSIS OF EFFECTS OF RME 1077

1.4 mm,20 and 2.73 mm,22 which corresponded to maxilla in all three dimensions, and the review
17%, 20%, and 33% of the total screw expansion, disclosed some interesting findings.
respectively. When treating posterior crossbites with a RME
device, the existing evidence points out that the
Circummaxillary Sutures midpalatal suture opening is around 20%–50% of the
total screw expansion. There seems to be no
The changes in the circummaxillary sutures were
consistent evidence on whether the midpalatal sutural
assessed in one study.9 The following sutures were
opening is parallel or triangular.
reported to be affected: zygomaticofrontal, zygomati-
The effect on the nasal cavity dimensions after RME
comaxillary, frontomaxillary, zygomaticotemporal, na-
seems to be apparent and indicates an enlargement
somaxillary, frontonasal, and internasal. The changes
between 17% and 33% of the total screw expansion. If
in these sutures were overall small, ie, between 0.30
this increase in dimensions facilitates the breathing
and 0.45 mm. The average amount of suture opening
mode of the patients, an interesting follow-up question
was generally higher in the sutures articulating directly
would be for how long; this question, however, was not
to the maxilla (zygomaticomaxillary and frontomaxil-
assessed in the included studies.
lary), whereas sutures further away from the maxilla
Circummaxillary sutures, particularly the zygomati-
showed a lower degree of disarticulation.
comaxillary and frontomaxillary sutures, appear to be
affected by the maxillary expansion, but the changes in
Spheno-occipital Synchondrosis
these sutures were overall small and the evidence not
One study demonstrated a mean expansion of conclusive. The investigations of the sutures were only
0.6 mm in the spheno-occipital synchondrosis.11 done in one plane of space and at the middle point of
the sutures, which is a shortcoming because no
Orbital Structures considerations were taken of the topography of the
investigated sutures at different sites. In addition, one
A significant increase in orbital volume and aperture
study showed a small opening of the spheno-occipital
width was found in one study.18 However, both the
synchondrosis after RME treatment.11 The involvement
increase in volume (0.72 mL) and width (1.09 mm)
of both the circummaxillary sutures and the spheno-
were small and considered clinically insignificant.
occipital synchondrosis can have some important
clinical implications and may explain the forward and
Dental Structures
downward displacement of the maxilla after RME
The dentoalveolar transverse expansion was larger treatment, which can be beneficial in Class III correc-
than the skeletal expansion.13,14,22 Dental tipping was tions in young patients.9 These findings are, however, a
assessed in four studies.13,14,19,22 Mean buccal tipping manifestation of the immediate effects of RME, and a
of the first molars was reported to be 7.5u in three systematic review of the long-term effects and critical
studies13,14,22 and 1.0u in the study by Podesser et al.21 analysis of longitudinal studies are essential.
Alveolar bending was also reported and accounted for The effect of RME on the dentoalveolar structures
about 30% of the total expansion.14 was found to be greater than the skeletal expansion.
Dental and alveolar tipping toward the buccal aspect
Quality Analysis was reported to occur in four studies. The clinical
implications of these ‘‘side effects’’ could imply
A quality analysis of the 10 retrieved studies was
overexpansion due to the risk for dental and alveolar
accomplished according to the criteria in Table 1.
relapse.
Interexaminer agreement for the quality assessment
The impact of age on skeletal vs dental effects of
was 0.95 (kappa statistics).
RME is an interesting issue in the clinical situation. The
The judged quality and methodologic soundness for
age range in the articles reviewed was 6.0 to
the 10 selected studies are presented in Table 3. Two
14.5 years. All of the studies except one22 showed,
studies were of medium quality,14,18 and the other eight
more or less, the same skeletal expansion rate, but
were of low quality. Obvious shortcomings were study
dental tipping varied. In the study by Podesser et al.,21
design, sample size, and inadequate selection descrip-
dental tipping was reported to be about 1u compared to
tion. Only three studies used blinded measure-
6.5u as reported in the studies by Christie et al.,22
ments,14,18 and dropouts were not reported in any study.
Lagravère et al.,13 and Weissheimer et al.14 Mean age
for patients in the study by Podesser21 was 8.1 years,
DISCUSSION
which is about 2 years younger than participants in the
This systematic review is the first review to evaluate studies conducted by Christie et al.22 and Weissheimer
the effect of RME treatment on sutures outside the et al.14 and 6 years younger than patients in the study

Angle Orthodontist, Vol 83, No 6, 2013

1078 BAZARGANI, FELDMANN, BONDEMARK

Table 2. Summarized Data of the 10 Included Studies

Author Year Country Study Design Participants Size, Gender, Age Intervention Type, Activation Protocol, Endpoints
Weissheimer 2011 Brazil Randomized Group I: 18 subjects Type:
et al.14 controlled Group II: 15 subjects Group I: Haas expander
trial (RCT) 22 girls, 11 boys Group II: Hyrax expander
10.7 y, (7.2–14.5) Activation: Initial activation of four quarter turns
(0.8 mm) followed by two quarter turns per d
(0.4 mm)
Endpoint: 8-mm screw activation

Sicurezza 2011 Italy Prospective 18 girls, 12 boys Type: Hyrax expander

et al.18 case-series 9.8 y (SD 1.8) Activation: three quarter turns per d (0.75 mm)
Mean treatment time: 18 d
Endpoint: palatal cusp of the first maxillary molar in contact
with the facial cusp of the mandibular first molar
Leonardi 2011 Italy1 Prospective 6 girls, 2 boys Type: Hyrax expander
et al.9 case-series 9.8 y (SD 1.8) Activation: three quarter turns per d (0.75 mm)
Mean treatment time: 18 d
Endpoint: palatal cusp of the first maxillary molar in
contact with the facial cusp of the mandibular first
molar

Ballanti 2010 Italy2 Prospective 10 girls, 7 boys Type: Haas expander

et al.20 case-series 11.2 y (8–14) Activation: two quarter turns (0.5 mm) per d for 14 d
(7 mm)
Endpoint: 7-mm screw activation

Christie 2010 USA Prospective 10 girls, 14 boys Type: bonded Haas expander
et al.22 case-series 9.9 y (7.8–12.8) Activation: two quarter turns per day (0.4 mm)
Endpoint: no endpoint defined
Mean screw activation: 8.19 mm

Lagravére 2010 Canada RCT Group I: Type:

et al.13 13 girls and 8 boys Group I: bone-anchored maxillary expander
14. 2 y (SD 1.32) Group II: tooth-anchored maxillary expander
Group II: Activation:
15 girls and 5 boys Group I: 1 healing week followed by 1 turn every other d
14.1 y (SD 1.35) Group II: two quarter turns (0.5 mm) per d
Endpoint: overcorrection of the crossbite
Leonardi 2010 Italy1 Prospective 6 girls, 2 boys Type: Hyrax expander
et al.11 case-series 9.8 y (SD 1.8) Activation: three quarter turns (0.75 mm) per d; mean
treatment time 18 d
Endpoint: palatal cusp of the first maxillary molar in contact
with the facial cusp of the mandibular first molar
Ballanti 2009 Italy2 Prospective 10 girls, 7 boys Type: Haas expander
et al.19 case-series 11.2 y (8–14) Activation: two quarter turns (0.5 mm) per d for 14 d
Endpoint: 7-mm screw activation

Lione et al.12 2008 Italy2 Prospective 10 girls, 7 boys Type: Haas expander
case-series 11.2 y (8–14) Activation: two quarter turns (0.5 mm) per d for 14 d
Endpoint: 7-mm screw activation

Podesser 2007 Austria Prospective 6 girls and 3 boys Type: cemented RME splint device
et al.21 case-series 8.1 y (6.1–9.8) Activation: two quarter turns (0.5 mm) per d
Endpoint: 7-mm screw activation

1
Patient material in Leonardi et al.9 and Leonardi et al.11 are the same.
2
Patient material in Ballanti et al.20, Ballanti et al.19, and Lione et al.12 are the same.

Angle Orthodontist, Vol 83, No 6, 2013

3D ANALYSIS OF EFFECTS OF RME 1079
Table 2. Extended
Outcome Measure Imaging Parameters Outcome and authors conclusions
Comparison of linear and angular measurement Type: cone beam computed tomography (CBCT) Rapid maxillary expansion (RME) produced signifi-
changes in the transverse plane: Measurements on coronal slices cant increase in all transverse dimensions.
- Intermolar width perpendicular to the nasal plane The expansion pattern was triangular with smaller effects
- Molar angulation Resolution: at the skeletal level compared to dental level.
- Anterior and posterior midpalatal 0.3 mm voxel size The opening of the midpalatal suture was larger in
suture opening the anterior part compared to the posterior part.
- Anterior and posterior apical base width The Hyrax produced significantly larger skeletal
effects and less tipping than the Haas.
Linear measurement of aperture width Type: RME produced a small but significant increase in
Orbital volume was calculated by defining Low-dose computed tomography (CT) (80 kV) orbital volume and aperture width.
contours on a series of slices Measurements on axial slices
Resolution:
Slice-thickness 0.5 mm
Linear measurement of circummaxillary Type: RME produced significant bony displacement by
suture width changes: Low-dose CT (80 kV) measurements circummaxillary suture opening. Sutures that
- Nasomaxillary on axial and sagittal slices articulate directly with the maxilla had larger
- Frontomaxillary Resolution: displacement than those located further away.
- Zygomaticomaxillary Slice-thickness 0.5 mm
- Internasal
- Zygomaticotemporal
- Frontonasal
Linear measurement changes in the Type: RME produced sign increase in all transverse
transverse plane: Low-dose CT (80 kV) dimensions.
- Interincisor width Measurements on coronal slices Midpalatal suture and nasal width increased in a
- Midpalatal suture width perpendicular to the occlusal plane parallel manner on coronal scans but were
- Nasal cavity width Resolution: larger anteriorly compared to posteriorly.
Slice-thickness 1.25 mm, interval 0.6 mm
Linear and angular measurement Type: CBCT RME produced significant increase in transverse
changes in the transverse plane: Measurements on coronal and sagittal slices dimensions of the nasal cavity, maxillary basal
- Intermolar angle Resolution: bone, and midpalatal suture.
- Midpalatal suture width No data The midpalatal suture opened in a parallel fashion but
- Basal bone width had the largest increase in the suture level followed
- Nasal cavity width by basal bone and nasal cavity level.
Comparison of linear and angular measurement Type: CBCT Transverse changes were significant and with no
changes in the transverse, vertical, Measurements on sagittal, axial, and differences between groups.
and sagittal plane: coronal slices Only minor changes in vertical and sagittal
- Intermolar angle Resolution: dimensions. Dental expansion was greater than
- Midpalatal suture width 0.25 mm voxel size skeletal expansion.
- Maxillary basal bone width
- Nasal cavity width
Linear measurement of spheno-occipital Type: RME led to a small immediate widening of the
synchondrosis width changes Low-dose CT (80 kV) Measurements on axial slices spheno-occipital synchondrosis.
Resolution:
Slice-thickness 0.5mm

Linear measurement changes in the Type: RME induced a significant increase in the trans-
transverse plane: Low-dose CT (80 kV) verse dimension of the maxillary arch without
- Intermolar width (crown and apex) Measurements on coronal scans causing permanent injury to the periodontal
- Lingual bone plate thickness perpendicular to the hard palate bony support of anchoring teeth.
Buccal bone thickness Resolution:
Slice-thickness 1.25 mm, interval 0.6 mm
Linear measurement changes in the Type: RME produced significant increase in the trans-
transverse plane: Low-dose CT (80 kV) verse dimensions of the midpalatal suture, more
- Midpalatal suture width Measurements on coronal scans anteriorly than posteriorly.
- Pterygoid width perpendicular to the hard palate Pterygoid width was also significantly
Resolution: increased.
Slice-thickness 1.25 mm, interval 0.6 mm
Linear and angular measurement changes in the Type: The relative contribution of dentoalveolar and
transverse plane: Low-dose CT skeletal changes varied from subject to subject.
- Intermolar width Measurements on coronal scans Almost 50% of the changes were a result of
- Intermolar angle Resolution: dentoalveolar changes
- Maxillary alveolar width Slice-thickness 1.5 mm, interval 1.5 mm
- Midpalatal suture width
- Maxillary basal bone width
- Nasal cavity width
1
Patient material in Leonardi et al. 2011 and Leonardi et al. 2010 are the same.
2
Patient material in Ballanti et al. 2010, Ballanti et al. 2009, and Lione et al. 2008 are the same.

Angle Orthodontist, Vol 83, No 6, 2013

1080 BAZARGANI, FELDMANN, BONDEMARK

Table 3. Quality Evaluation of the 10 Selected Studies According to Predetermined Criteria (Table 1)
Adequate
Author Year Country Study Design Sample Size
Weissheimer et al.14 2011 Brazil Randomized controlled trial (RCT) Partly adequate
Sicurezza et al.18 2011 Italy Prospective case-series Yes
Leonardi et al.9 2011 Italy Prospective case-series Inadequate
Ballanti et al.20 2010 Italy Prospective case-series Partly adequate
Christie et al.22 2010 USA Prospective case-series Yes
Lagravére et al.13 2010 Canada RCT Yes
Leonardi et al.11 2011 Italy Prospective case-series Inadequate
Ballanti et al.19 2009 Italy Prospective case-series Partly adequate
Lione et al.12 2008 Italy Prospective case-series Partly adequate
Podesser et al.21 2007 Austria Prospective case-series Inadequate

conducted by Lagravère et al.13 This age difference have argued that well-designed prospective or even
could be one of the factors explaining the lesser dental retrospective studies should not be ignored when
tipping in younger children. assessing scientific literature.24 Nevertheless, it should
In contrast to the 2D imaging, CT/CBCT and its be emphasized that the randomized controlled trial with
impact on more accurate diagnostics in all three adequate sample size and power is the most powerful
dimensions is very encouraging due to greater tool to evaluate treatment, and the quality of the trial
resolution and without structure. CT/CBCT enables significantly affects the validity of the conclusions.
assessment of root resorption, determine positions of Many of the studies had serious defects, and
impacted teeth, evaluation of bone grafts in cleft according to the criteria used, the majority of the articles
regions and treatment effects of RME. If the structural were judged to be of low quality. The most serious
overlap is the main issue in the diagnostics, the use of shortcomings were the study design in combination with
the low-dose CT/CBCT imaging can be justified for small sample size and inadequate selection description.
gathering the most adequate information for the Other examples of shortcomings were lack of method
treatment. However, the radiation dosage and its error analysis and the absence of blinding in measure-
bearing on growing patients must be kept in mind. ments. Furthermore, several studies used the same
Even though CT-imaging may be available, regular material (patient data). In addition, all studies used
use of it for orthodontic or dental care may not be measurements on 2D slices, which imply accuracy
justified. problems when identifying the same slice and land-
The restrictions concerning the number of databas- marks between the baseline and posttreatment slices.
es and languages when searching the literature might 3D modeling and superimposition on stable structures
imply that some studies were not identified. Studies is one way to solve this problem and makes it easier to
that are difficult to find are, however, often of lower identify the same landmark, and thus, gives rise to more
quality. The strength of the evidence in a systematic accurate and reliable measurements.
review is probably more dependent on assessing the In the reviewed articles, different endpoints and
quality of the included studies than on the degree of different CT/CBCT protocols with various slice thick-
comprehensiveness.23 nesses and somewhat different reference points were
The kappa scores measuring levels of agreement used as well as different resolutions. This can
between the two reviewers in assessing data extraction compromise the quality of the images, and thereby
and quality scores of the included articles were very have an impact on the reliability of the results.
good, and thus, indicated that the results were reliable. Therefore, it might be sound to interpret the results
from these studies with caution.
Limitations This review of the literature has disclosed that additional
randomized controlled trials with sufficient power are
No meta-analysis was carried out because of the required to add further insight into the 3D effects of rapid
diversity in the methodologic aspects in the selected maxillary expansion on sutures and bones of the face, and
studies such as different landmarks, reference points, thus, has exposed a need for future studies in this area.
and endpoints.
A notable finding was that none of the selected CONCLUSIONS
studies were of high value of evidence, and only two
The available evidence indicates that:
randomized controlled trials were identified. From an
evidence-based point of view, the scientific value of a N Midpalatal suture opening during orthodontic treat-
case-series study is limited. Some authors, however, ment with RME amounted to 20%–50% of the total

Angle Orthodontist, Vol 83, No 6, 2013

3D ANALYSIS OF EFFECTS OF RME 1081

Table 3. Extended
Adequate Selection Defined Diagnosis Valid Outcome Method Error Blinding in Judged Quality
Description and Endpoints Measures Analysis Measurements Grading
Inadequate Yes Yes Yes Yes Medium
Inadequate Yes Yes No Yes Medium
Inadequate Unclear Yes No Yes Low
Inadequate Yes Partly Yes No Low
Inadequate No Yes Yes No Low
Partly adequate No Yes Yes No Low
Inadequate Unclear Yes No No Low
Inadequate Yes Partly Yes No Low
Inadequate Yes Partly Yes No Low
Inadequate No Partly No No Low

screw expansion, but there was no consistent 8. Haas A. Rapid expansion of the maxillary dental arch and
evidence on whether the midpalatal sutural opening nasal cavity by opening the mid palatal suture. Angle
Orthod. 1961;31:73–89.
was parallel or triangular.
9. Leonardi R, Sicurezza E, Cutrera A, Barbato E. Early post-
N RME produced immediate significant changes in treatment changes of circumaxillary sutures in young
transverse dimensions of the nasal cavity, circum- patients treated with rapid maxillary expansion. Angle
maxillary sutures, spheno-occipital synchondrosis, Orthod. 2011;81:36–41.
and aperture width. Structures that articulated 10. Ghoneima A, Abdel-Fattah E, Hartsfield J, El-Bedwehi A,
directly with the maxilla had larger displacement Kamel A, Kula K. Effects of rapid maxillary expansion on the
cranial and circummaxillary sutures. Am J Orthod Dentofa-
than those located further away. cial Orthop. 2011;140:510–519.
N The majority of the articles were judged to be of low 11. Leonardi R, Cutrera A, Barbato E. Rapid maxillary expan-
quality therefore, no evidence-based conclusions sion affects the spheno-occipital synchondrosis in young-
could be drawn from these studies. Additional sters. A study with low-dose computed tomography. Angle
randomized controlled trials with sufficient power Orthod. 2010;80:106–110.
12. Lione R, Ballanti F, Franchi L, Baccetti T, Cozza P.
are required to add further insight into the 3D effects
Treatment and posttreatment skeletal effects of rapid
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