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Rapid maxillary expansion: Effects on palatal area investigated by computed

tomography in growing subjects

Article  in  European Journal of Paediatric Dentistry · September 2012

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 R. Lione, C. Pavoni, G. Laganà, E. Fanucci*,
L. Ottria**, P. Cozza
Department of Orthodontics, University of Rome “Tor Vergata”,
Rome, Italy
*Department of Radiology
**Department of Odontostomatology
e-mail: robertalione@yahoo.it
Rapid maxillary
expansion: effects
on palatal area
investigated by
computed tomography
in growing subjects
abstract
Aim The aim of this prospective study was to evaluate
the effects of rapid maxillary expansion (RME) on
the palatal area as assessed by low-dose CT before
treatment (T0), at the end of active expansion (T1) and
after a retention period of 6 months (T2).
Materials and Methods The study sample
comprised 17 prepubertal subjects (mean age 11.2
years) with constricted maxillary arches. Total amount
of expansion was 7 mm in all subjects. Multi-slice low-
dose CT scans were taken at T0, T1, and T2. On axial
CT scanned images a circle line corresponding to the
palatal area was drawn and the area inside the circle
registered at all three observation times. The area was
measured in mm2. Statistical comparisons were carried
out with Friedman test with post-hoc tests (P<0.05).
Results The palatal area showed a significant increase
from T0 to T1 and from T0 to T2 as a consequence of
the opening of the midpalatal suture after RME.
Conclusion Opening the midpalatal suture by using
orthopedic forces allowed to extend the area of the
maxilla. After a 6-months retention period the palatal
area demonstrated a stable increase due to a bone
deposition along the midpalatal suture in both the
anterior and posterior parts of the maxilla.
Keywords Computed tomography; Imaging 3D;
Palatal vault; Rapid maxillary expansion.
European Journal of Paediatric Dentistry vol. 13/3-2012
Introduction
The correlations and connections between the
stomatognathic system and other apparatuses are
often the object of investigations. In particular, the
correction of skeletal transverse problems of the maxilla
can be associated with favourable therapeutic effects
on hearing, swallowing and nasal breathing [Braun,
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
hearing loss after treatment because the palatal area
is the area where the tongue should be located and
the palatal processes of the maxilla correspond to the
floor of the nasal cavities [Ceylan et al., 1996; Basciftci
et al., 2002; Buccheri et al., 2004]. Indeed patients
with constricted maxillary arches tend to posture the
tongue in a low position and the expansion of the
palatal region allows to reduce low or forward tongue
posture [Brodie, 1950]. RME causes improvements in
nasal respiration and in oral posture by increasing the
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
this procedure were substantiated by radiography
[Derichsweiler, 1953; Krebs, 1964]. In the literature a
wide standard radiographic documentation is reported
and 3D more sophisticated techniques for evaluation
of morphological changes in the dentofacial complex
have been proposed in the last ten years [Sandikcioglu
and Hazar, 1997; da Silva Filho et al., 1995; da Silva
Filho et al., 2006; Podesser et al., 2007]. In particular
the effects of RME on the palatal vault have been
analysed by linear measurements on dental casts,
on posteroanterior cephalograms, and on computed
tomography (CT) scanned images [Rungcharassaeng
et al., 2007; Lione et al., 2008; Ballanti et al., 2009;
Garib et al., 2005; Habersack et al., 2007; Garret et al.,
2008; Phatouros et al., 2008]. Currently, the number
of scientific investigations conducted on CT scans is
limited, while it would add valuable information to
existing observations on axial CT scans of the palatal
area.
The aim of this prospective study was to analyse
the changes of the palatal area after RME as assessed
by low-dose CT before treatment (T0), at the end of
active expansion (T1) and after a retention period of
6 months (T2). The palatal area was studied by using
a diagnostic tool reported in literature to evaluate
glenoid bone loss [Nofsinger et al., 2010].
This radiographic method of investigation is able
to show the modification of the palatal area after
treatment by using a standardised circle area that is
not influenced by tooth position, alveolar and skeletal
morphology.
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


T0 T1
Mean SD Mean SD
Circle area (mm2) 525.6 125.2 691.3 97.7
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
measurements after one month. Systematic and
random errors on the measures repeated on the 17
subjects at all observations periods were calculated with
paired t-tests and Dahlberg’s formula [Dahlberg, 1940],
respectively. No statistically significant differences (P >
0.05) were found between the first and the second
measurements for any of the analysed variables; the
range for random errors was 0.1 to 0.3 mm2.
Friedman test with Tukey’s post-hoc tests was used
(P<0.05). All statistical computations were performed
with a statistical software (SigmaStat 3.5, Systat
Software Inc., Point Richmond, Ca, USA). The level of
significance was set at p<0.05.
Results
The midpalatal suture was opened in all subjects.
The circle area showed a significant increase from T0 to
T1 (+165.7 mm2,) as a consequence of the opening of
the midpalatal suture after RME. A significant increase
from T0 to T2 (+195.5 mm2) and lack of statistically
significant differences from T1 to T2 (+29.8 mm2), was
observed (Table 1).
Discussion
The purpose of this study was to analyse the
treatment and post-retention effects of RME on the
palatal area on axial CT scans. Similar measurements
have been attempted in previous studies but research
was limited to using 2D X-ray or casts model for
data acquisition [Haas, 1961; Starnbach et al., 1966;
Wertz, 1970]. The method used in the present study
was previously described in literature to evaluate the
anterior part of the glenoid in anterior glenohumeral
instability, based on the typically circular geometry
of the inferior glenoid. A three-dimensional (3D)-
reconstructed computerised tomography en face
images of the glenoid with "subtraction" of the
humeral head was used to overlay a perfect circle
that was fit to the glenoid. The anterior aspect of the
circle was then adjusted to match the true anatomic
contour of the anterior glenoid. This adjusted region
European Journal of Paediatric Dentistry vol. 13/3-2012
RME ANALYSED BY by computed tomography
T2 Comparisons of the means
Mean SD T0 vs. T1 T1 vs. T2 T0 vs. T2
721.1 92.7 165.7 * 29.8 ns 195.5 *
was used to determine the percentage of the perfect
circle occupied by the glenoid creating an anatomic
preoperative description of bone loss [Nofsinger et al.,
2010].
Computed Tomography (CT) analysis of RME effects
gives better quality and accuracy of the diagnostic
parameters measured, and it might soon become the
routine analysis for patients undergoing such treatment
[Habersack al., 2007; Phatorous et al., 2008]. To our
knowledge, the present investigation is the first attempt
to use a 3D scanning technique to assess morphologic
palatal changes after expansion therapy by using a
standardised circle area that is not influenced by tooth
position, alveolar and skeletal anatomy.
The total expansion of the palatal area with an RME
appliance can be divided in skeletal expansion and
alveolar bending. The first one is due to the direct
separation of the maxillary halves as a result of the
opening of the midpalatal suture, while the alveolar
bending is an additional expansion at the buccal
alveolar plate [Garret et al., 2008]. At the end of active
treatment (T1) the net increase in area was 165.7 mm2.
This data might suggest that expansion of constricted
maxillary arch produces marked increases in the area
of the palate and it can be assumed that the marked
increase in the palatal area is a result of the midpalatal
suture opening in conjunction with alveolar arch
tipping. Moreover using a circle area it was possible to
demonstrate that RME increased transverse dimension
without reducing the arch perimeter. When the circle
areas obtained at T0, T1, T2 are superimposed on one
point (the external aspect of the palatal cortical plate of
the right maxillary first molar), it is pointed out that the
orthopedic expansion affected the palatal area in both
transverse and sagittal dimensions (Fig.2). This effect
was due to the opening of the midpalatal suture that
is decreasing from the anterior to the posterior part of
the palate.
After a 6-month retention period (T2) the palatal
area resulted stable with an additional value of 29.8
mm2 during the T1-T2 interval. The appliance was
maintained in place as a passive retainer for 6 months
to allow complete recovery and reorganisation of the
midpalatal suture and to avoid a relapse of skeletal
effects in both the oral and nasal cavity.
217
 Lione R. et al.
Conclusions
› Opening the midpalatal suture by using orthopedic
forces allowed to extend the area of the maxilla (T1)
increasing the transverse dimension and without
reducing the arch perimeter.
› After a 6-months retention period (T2) the palatal
area demonstrated a stable increase due to bone
deposition along the midpalatal suture in both the
anterior and posterior parts of the maxilla.
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