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Do changes in spheno-occipital synchondrosis after rapid maxillary

expansion affect the maxillomandibular complex?

Article in European Journal of Paediatric Dentistry · March 2013

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A. Silvestrini-Biavati, F. Angiero*, A. Gambino,
A. Ugolini
University of Genoa, Italy
Department of Surgical Sciences, Orthodontics Unit
*Department of Surgical Sciences, the University of Genoa, Italy
e-mail: armando.silvestrini@tin.it
Do changes in
spheno-occipital
synchondrosis after
rapid maxillary
expansion affect
the maxillomandibular
complex?
abstract
Aim This was to evaluate changes in spheno-occipital
synchondrosis one year after rapid maxillary expansion
(RME), in order to assess the influence that any
change might have on sagittal and vertical skeletal
cephalometric variables.
Materials and methods Patients were selected
consecutively and grouped into: Group 1 comprised
30 Caucasian patients (13 m; 17 f) undergoing RME
therapy; after active expansion therapy, the Haas
expander was worn as passive retainer for an average
of 7 months. Group 2 as control included 14 untreated
subjects (6 m, 8 f), matched by age, sex and vertebral
skeletal maturity (CVM method, stages 1-3). Six
cephalometric variables concerning spheno-occipital
synchondrosis were studied: N-S-Ba°; SOS-Ba; SOS-S;
S-Ba; Ba-N; S-N; nine skeletal variables for sagittal and
vertical evaluation were also checked. T-test was used
for comparing the 2 groups data.
Results A statistically-significant opening of the
spheno-occipital synchondrosis and increase of the
posterior cranial base length (Ba-SOS) were found
between group 1 and 2. After 1 year, these modifications
in spheno-occipital syncondrosis produced no change
in the anteroposterior or vertical skeletal parameters
examined.
63
art_sincondrosi.indd 63
Conclusion After RME there were statistically-
significant effects on spheno-occipital synchondrosis
length and cranial base angle; however, these changes
in the mid-term did not affect the vertical or sagittal
parameters of the skeletal maxillomandibular complex.
Keywords Cranial base angle; Rapid maxillary
expansion; Spheno-occipital synchondrosis.
Introduction
Rapid maxillary expansion (RME) is indicated in
the treatment of maxillary transverse deficiency and
unilateral or bilateral crossbite. RME is used in order to
widen the midpalatal suture and to correct maxillary
and dental transverse discrepancies. The maxilla is
connected with several bones in the head through
sutures: frontomaxillary, frontonasal, frontozygomatic,
nasomaxillary, zygomaticomaxillary, temporozygomatic,
pterygomaxillary, internasal. When orthopedic forces
are applied from RME activation to the maxillary basal
bone, they may be transmitted on closed facial bones.
Therefore RME may affect structures directly or indirectly
related to the maxilla [Ballanti et al., 2010; Christie et al.,
2010; Sun et al., 2011; Martina et al., 2012; Farronato et
al., 2012]. Baydas et al. [2006], Cordasco et al. [2012],
Leonardi et al. [2012] included the nasal cavity, the
pharyngeal structures, the temporomandibular joints and
the pterygoid process of the sphenoid bone; Leonardi et
al. [2010], reported indirect effects of RME even on the
spheno-occipital synchondrosis. The effect of orthopedic
forces on the craniomaxillary sutures have been studied
[Ghoneima et al., 2011]: animal-based research found
histologic changes in suture tissue after orthopedic forces
were applied, such as stretching of sutural connective
tissue fibers and new bone deposition along the
stretched fibers. Not all studies agree about the suture
and bones involved during RME therapy. Gardner and
Kronman [1971] found changes in lambdoid, parietal,
and midsagittal sutures in rhesus monkeys; Kudlick
[1973] postulated the involvement of all craniofacial
bones adjacent to the maxilla, except the sphenoid
bones. Wertz and Dreskin [1977] found that the maxilla
moved downward and forward during midpalatal suture
opening; conversely, Timms [1980] showed that the
maxilla and palatine bones moved apart, along with the
pterygoid processes of the sphenoid bone. Leonardi et
al. [2010] reported the opening of zygomaticomaxillary,
frontomaxillary and internasal sutures.
Suture changes after RME therapy have been
suggested to induce changes in the craniofacial complex
growth. In particular, it has been hypothesised that the
cranial base is a guide for the development of the maxilla,
midface, and lower facial complex, and its modification
European Journal of Paediatric Dentistry vol. 14/1-2013
19/02/13 17:16
 Silvestrini-Biavati A. et al.
could affect the maxillomandibular complex [Proff et al.,
2008]. To asses this hypothesis, the effects of RME on
the cranial base and the spheno-occipital synchondrosis
have been investigated [Iseri et al., 1998; Jafari et al.,
2003; Baydas et al., 2006; Holberg and Rudzki-Janson,
2006; Rukkulchon and Wong, 2008; Cendekiawan et al.,
2008; Leonardi et al.,2010]. Some of these studies have
hypothesised that opening of the synchondrosis could
account for the forward and downward displacement
of the maxilla. Some studies report a downward and
forward movement of the maxilla when the midpalatal
suture opens, due to displacement of the maxillocranial
sutures [Garib et al., 2005]. Some of these studies are
limited to short-term evaluation; some lack control
groups, and others are based on animal or experimental
models, such as finite element analyses.
The aim of this controlled study is to evaluate changes
in cranial base features one year after RPE therapy, in
order to assess the influence such changes may have on
sagittal and vertical skeletal cephalometric variables.
Materials and methods
Subjects were treated from 2008 to 2011 at the
Department of Orthodontics, Faculty of Dentistry, Genoa
University; they were selected consecutively, according
to skeletal maturity as evaluated by means of the CVM
method [Baccetti et al., 2006]. All subjects presented
cervical vertebral stages 1-3 (CVS 1–3) evaluated on
lateral cephalograms, at T1. Exclusion criteria were:
previous orthodontic treatment, hypodontia in any
quadrant (excluding third molars), hormonal imbalance,
temporomandibular joint symptoms, craniofacial
abnormalities, arthritis, inadequate radiographs (poor
quality at the cranial base area or unknown magnification
factor).
Thirty patients matched with inclusion criteria (13 m, 17
f; mean age 8.0±1.5 years, at T1). Subjects’ characteristics
were: Class I or Class II division 1 malocclusion (18 and 12
patients, respectively) with transverse maxillary deficiency
and posterior unilateral crossbite at treatment onset (T1).
The records available included dental casts, panoramic
radiographs and lateral cephalometric head films at pre-
treatment stage (T1) and one year after the end of active
expansion (T2). The study group (group 1) underwent
tooth-tissue supported (Haas type) RME, expanded by
2 turns a day (0.20 mm per turn). When the desired
overcorrection for each patient had been achieved, the
appliance was stabilised. Expansion was considered
adequate when the occlusal aspect of the maxillary
lingual cusp of maxillary first molars contacted the
occlusal aspect of the facial cusp of the mandibular lower
first molars. The Haas expander remained on the teeth
as passive retainer for an average of 7 (SD ±2) months,
after which a removable palatal plate, with Adams clasp
on the first maxillary molars, was worn full-time. T2 was
64
art_sincondrosi.indd 64
after a minimum of 6 months of removable palatal plate
wear (1.1±0.4 years, at T2). For all patients, crossbite was
corrected at the end of active expansion.
The control group (group 2) comprised 14 subjects (6
m, 8 f; mean age 7.6±1.7 years, at T1) with untreated
cross-bite, matched by age, sex and skeletal maturity.
Control subjects presented Angle Class I (n=8) or Class
II, division 1 (n=6) malocclusions and transverse maxillary
deficiency with posterior unilateral crossbite; they had
postponed orthodontic treatment for economic reasons.
Cephalometric analysis
Cephalograms were traced digitally, by a single
examiner, using Ceph Basic v.1.0.4 software (Image
Instruments GmbH, Chemnitz Germany). Landmark
location and accuracy of the anatomic outlines was
verified by a second senior clinician (ASB). Cephalometric
points selected are showed in figures 1 and 2. Six cranial
base measurements [N-S-Ba°; SOS-Ba(mm); SOS-S(mm);
S-Ba(mm), S-N(mm) and Ba-N(mm)] and eight skeletal
variables (SNA°; SNB°, AFH/PFH(mm), Jarabak’s Sum S°,
S-N/Go-Me°, N-S-Ar°, S-Go(mm) and Ar-Go-Me°) were
determined. To analyse method error, five randomly-
selected lateral cephalometric radiographs were digitally
retraced. A combined error of landmark location, tracing,
and measurement was determined. Intraclass correlation
coefficients (ICC) were used to determine intra- and
inter-rater agreement for each cephalometric variable.
Correlation coefficients for the skeletal measures were
greater than 0.95. Linear measurement errors averaged
0.4 mm (SD 0.6 mm), and angular measurement errors
averaged 0.5° (SD 0.5°).
Statistical analysis
Descriptive statistics were calculated for each variable.
The Shapiro-Wilks test demonstrated the normal
distribution of data, thus parametric statistics could be
applied. Patients’ data were compared with data from
the control group using parametric t-tests. Probabilities
of <0.05 were accepted as significant in all statistical
analyses. The power of the study was adequate (>0.83),
calculated a priori using the mean values and standard
deviations of N-S-Ba° reported by Maestripieri et al.
[(2002] at an alpha of 0.05.
Results
There were no significant differences between the two
groups regarding age and skeletal maturity. No significant
differences in any of the variables used in the study were
found between genders, thus data concerning the two
genders were pooled for analysis. Baseline (T1) and follow-
up (T2) cephalometric measurements are summarised in
Table 1. During the treatment period (T1 to T2), study and
control groups showed significant changes in all cranial
base variables, except for N-S-Ba (°) and BA-SOS (mm)
European Journal of Paediatric Dentistry vol. 14/1-2013
19/02/13 17:16
 Relationship between synchondrosis and the maxillomandibular complex
fig. 1 Cephalometric analysis: Gonion (Go), Menton (Me), Nasion
(N), Articulare (Ar), Sella turcica (S), A point (A), B point (B), Basion
(Ba), Sphenoccipital Synchondrosis (SOS), the most posterior point
of the spheno-occipital synchondrosis on the sphenoid bone.
fig. 2 Spheno-
occipital
synchondrosis
area: SOS-S
(mm); SOS-Ba
(mm); S-Ba
(mm).
in the control group. A statistical comparison of changes
from T1 to T2 in RME group versus control group showed
significant differences in three cranial base variables (N-S-
Ba°, Ba-SOS, S-Ba). There was no statistical difference
between the two groups regarding sagittal and vertical
changes (Table 1).
Discussion
A recent CT scan study on patients with transverse
maxillary deficiency showed that intermaxillary, internasal,
nasomaxillary, frontomaxillary, and frontonasal sutures
were affected by the mechanical forces generated by
RME [Ghoneima et al., 2001]. After RME therapy, another
study found significant opening in zygomaticomaxillary,
frontomaxillary and internasal sutures [Leonardi et al.,
2011]. Unfortunately, neither of these studies analyses
changes in the spheno-occipital synchondrosis. Although
various studies have demonstrated that the posterior
cranial base and spheno-occipital synchondrosis are
involved during RME therapy, only recently a clinical CBCT
European Journal of Paediatric Dentistry vol. 14/1-2013
art_sincondrosi.indd 65
study showed that RME leads to a significant immediate
widening of the spheno-occipital synchondrosis in
young subjects [Leonardi et al., 2010]. Opening of the
spheno-occipital synchondrosis and stresses acting upon
the cranial base during RME therapy have also been
demonstrated in finite element studies [Iseri et al., 1998;
Jafari et al., 2003; Holberg and Rudzki-Janson, 2006],
and animal model research [Rukkulchon and Wong,
2008; Cendekiawan et al., 2008].
Although the radiation dose of a CBCT scan is lower
than that of a CT scan, CBCT is not suitable for regular
monitoring of orthodontic patients and it is questionable
whether it is appropriate to perform more than one
CBCT scan per year. Moreover, Kokich [2010] suggested
that ethical implications should be examined about
CBCT, since it is not known which orthodontic cases
benefit from 3D imaging, and what risks might be
entailed in a CBCT scan, especially in growing patients.
For these reasons, in order to avoid any X-ray damage to
the patients involved in this study, we analysed changes
occurring to the cranial base region after RME therapy
on traditional cephalograms. The group of patients who
underwent RME treatment was compared to a group
of untreated control subjects, matched by age, sex and
skeletal maturity. All subjects were selected before the
pubertal peak (CVM 1–3), since it has been shown that,
at these three stages, RME patients undergo significant
and more effective long-term changes at the skeletal
level, in both maxillary and circummaxillary structures
[Baccetti et al., 2001].
The control group of untreated subjects was also used
to identify confounding factors, such as the expression of
craniofacial growth and development during the study
period. The untreated group showed craniofacial growth
with significant changes in the same variables, except
for N-S-Ba° and Ba-SOS. The statistical comparison
of the changes between T1 and T2 in the two groups
demonstrated significant differences in the three cranial
base variables (N-S-Ba°, Ba-SOS, S-Ba) (Table 2). These
results support the hypothesis of a potential involvement
of the cranial base structures during RME therapy.
Specifically, we found a small but statistically significant
opening of the cranial base angle (N-S-Ba°) in the RME
group, with an increase in the posterior cranial base length
(BA-SOS). The cranial base angle and spheno-occipital
synchondrosis are interesting due to the relationship
between the degree of cranial base flexion and type
of malocclusion that has been suggested [Dhopatkar
et al., 2002]. The spheno-occipital synchondrosis is
also involved because growth of this structure causes
the anterior cranial base with its attached maxillary
complex to displace upward and forward, away from the
foramen magnum. The mandible, maintaining a constant
sagittal relationship with the foramen magnum, grows
downward and forwards, away from the cranial base
[Coben, 1998].
In our study, we found that all sagittal variables in the
65
19/02/13 17:16
 Silvestrini-Biavati A. et al.

RME Group (n=30) Control Group (n=14) tabLE 1 Statistical

T1 T2 p T1 T2 p Comparison of T1–T2
Age (y) Mean 8 9.1 7.5 8.5 Changes. SD: standard
SD 1.5 1.7 1 1.1 deviation; NS: not significant.
AFP/PFH (%) Mean 6.9 64.3 NS 65.3 64.8 NS
SD 6.2 5.8 6.5 5.7
SNA° Mean 80.1 80.5 NS 78.9 79,3 NS
SD 3.2 3.5 3.8 4
SNB° Mean 77.5 77.9 NS 76.6 77.1 NS
SD 3.5 3.4 3.6 3.8
S/N-Go/Me° Mean 35.3 36 NS 35.6 36.1 NS
SD 6 6.3 6.4 6.5
N-S-Ba° Mean 132.8 133.9 <0.01 130.1 130.5 NS
SD 6 5.8 4.3 4.5
Ba-SOS (mm) Mean 27.8 28.8 <0.01 28.1 28.4 NS
SD 3.5 3.6 2.2 2.7
S-SOS (mm) Mean 16.2 17.2 <0.01 15.8 16.3 0.03
SD 2 2.2 1.6 1.9
S-Ba (mm) Mean 43 44.9 <0.01 42.6 43.4 0.01
SD 3.3 3.8 2.2 2.3
Ba-N (mm) Mean 103.4 105.4 <0.01 104.6 105.7 0.01
SD 7.1 7 6.9 6.7
Σ (°) Mean 397.1 398.2 NS 396.3 396.9 NS
SD 5.1 4.3 4.8 5.4
N-S-Ar (°) Mean 121.9 122.5 NS 122.4 123.0 NS
SD 4.1 3.9 4.7 5.2
Ar-Go-Me (°) Mean 128.6 129.3 NS 127.8 128.6 NS
SD 5.8 5.3 5.1 5.3
S-Go (mm) Mean 71.4 72.3 NS 70.7 71.8 NS
SD 4.7 5.4 4.3 4.9
S-N (mm) Mean 72.4 74.6 <0.01 72 73.9 0.02
SD 3.2 3.8 3.5 4.3

Net Difference T2-T1 RME Group Control Group p tabLE 2 Statistical

Age (y) 1.1 1 NS Comparison of T1–T2
AFP/PFH (%) -0.6 -0.5 NS net differences. NS: not
SNA° 0.4 0.4 NS significant.
SNB° 0.4 0.5 NS
N-S-Ba° 1.1 0.4 0.03
Ba-SOS (mm) 1 0.3 0.04
S-SOS (mm) 1 0.5 NS
S-Ba (mm) 1.9 0.8 <0.01
Ba-N (mm) 2 1.1 NS
Σ (°) 1.1 0.6 NS
S-N/Go-Me(°) 0.7 0.5 NS
N-S-Ar (°) 0.6 0.6 NS
Ar-Go-Me (°) 0.7 0.8 NS
S-Go (mm) 0.9 1.1 NS
S-N (mm) 2.2 1.9 NS

RME group were similar in value to those of the control modifications. It is widely reported that, immediately after
group, throughout the study period (Table 1) and that they expansion, there is a downward maxillary displacement
did not show any significant correlation with cranial base and an extrusion of the supporting teeth, leading to

66 European Journal of Paediatric Dentistry vol. 14/1-2013

art_sincondrosi.indd 66 19/02/13 17:16

 Relationship between synchondrosis and the maxillomandibular complex
downward and backward mandibular rotation; however,
this is thought to be an ephemeral phenomenon [Garib
et al., 2005; Lagravere et al., 2005; Lagravere et al.,
2006]. We found no significant differences in the vertical
skeletal variables one year after expansion therapy.
As several studies have shown, although RME causes
vertical maxillary displacement, this vertical alteration
is not significant in the mid- or long-term [Garib et al.,
2005; Lagravere et al., 2005; Lagravere et al. 2006].
Involvement of the spheno-occipital synchondrosis might
have important clinical implications, such as the beneficial
effect of RME in young Class III patients, because the
suture opening might displace the maxilla forward and
downward [Leonardi et al., 2010], but there is no general
agreement [Garib et al., 2005] that, when the midpalatal
suture opens, the maxilla moves downward and forward,
because of the placement of the maxillocranial sutures.
We obtained results similar to those of reports
[Velasquez et al, 1996; Chang et al, 1997; Garib et al.,
2005; Lagravere et al., 2005; Lagravere et al. 2006],
showing that the skeletal changes in patients treated
with RME were non clinically relevant, after taking
into consideration the natural alterations resulting from
individual facial growth. However we foud that maxillary
expansion therapy did produce significant changes in
the spheno-occipital syncondrosis area, but that these
changes had not modified the craniofacial complex one
year after the active expansion phase, neither in the
sagittal nor in the vertical planes.
Conclusions
This mid-term controlled study showed that RME
therapy leads to immediate significant effects on the
spheno-occipital synchondrosis: an opening of the
cranial base angle and an increase of the posterior cranial
base length (Ba-SOS). One year after RME therapy, these
changes had not modified the craniofacial complex in
either the sagittal or the vertical skeletal patterns.
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