Original Article

Comparison of dimensions and volume of upper airway before and after

mini-implant assisted rapid maxillary expansion
Qiming Lia; Hongyi Tanga; Xueye Liua; Qing Luoa; Zhe Jianga; Domingo Martinb; Jing Guoc

ABSTRACT
Objectives: To evaluate changes in dimensions and volume of upper airway before and after mini-
implant assisted rapid maxillary expansion (MARME) and observe correlations between changes of
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upper airway and vertical skeletal pattern in young adults.

Materials and Methods: In this retrospective study, 22 patients (mean age, 22.6 6 4.5 years; 4
male 18 female) with transverse discrepancy underwent MARME. Cone beam computed
tomography was taken before and 3 months after expansion. Vertical and horizontal dimensions
and volume of the nasal cavity, nasopharyngeal, retropalatal, retroglossal and hypopharyngeal
airway were compared before and after MARME. Correlations between changed volume and
dimensions were explored, as well as the vertical skeletal pattern.
Results: Nasal osseous width, maxillary width, volume of the nasal cavity and nasopharynx
increased significantly (P , .05). Enlarged nasopharyngeal volume correlated with increased nasal
width at the PNS plane (P , .05). There were no correlations between expanded volume and
maxillary width. No measurements except nasal cavity volume had a correlation with Sum angle.
The Angle Orthodontist

Increased maxillary width correlated negatively with hard palate thickness (P , .05).
Conclusions: (1) MARME caused an increase in volume of the nasal cavity and nasopharynx, with
expansion of nasal osseous width and maxillary width. (2) Enlarged nasal width at the PNS plane
contributed to the increase in nasopharynx volume. Enlarged maxillary width showed no direct
relation with increased volume. (3) In this study, it was unclear about the association between
changes of the upper airway and vertical skeletal pattern because of complex structures. (4) Palate
thickness affected skeletal expansion of the maxilla in MARME. (Angle Orthod. 0000;00:000–000.)
KEY WORDS: Upper airway; Mini-implant assisted rapid maxillary expansion; CBCT; Cephalometry

a
Postgraduate Student, Department of Orthodontics, School
and Hospital of Stomatology, Shandong University; and Shan-
dong Key Laboratory of Oral Tissue Regeneration; and
Shandong Engineering Laboratory for Dental Materials and Oral
Tissue Regeneration, Jinan, Shandong Province, China.
b
Professor, Department of Orthodontics, Universidad Inter-
national de Cataluña, Barcelona, Spain.
c
Professor, Department of Orthodontics, School and Hospital
of Stomatology, Shandong University; and Shandong Key
Laboratory of Oral Tissue Regeneration; and Shandong Engi-
neering Laboratory for Dental Materials and Oral Tissue
Regeneration, Jinan, Shandong Province, China.
Corresponding author: Dr Jing Guo, Professor, School of
Stomatology, Shandong University, No.44-1 Wenhua Road
West, 250012 Jinan, Shandong, China
(e-mail: guojing@sdu.edu.cn)
Accepted: December 2019. Submitted: July 2019.
Published Online: February 11, 2020
Ó 0000 by The EH Angle Education and Research Foundation,
Inc.
INTRODUCTION
Rapid maxillary expansion (RME) is a common
orthodontic treatment procedure to correct transverse
discrepancies.1 Expansion of the midpalatal suture
affects the nasal floor and the effects extend to the
surrounding nasal and craniofacial structures.2 There-
fore, the effect of RME on the upper airway in three
dimensions was studied.3–5 In previous studies, nasal
cavity volume increased and nasal resistance re-
duced.6,7 However, not all studies reported an increase
in pharyngeal airway volume.5,8
In studies regarding the effect of conventional tooth-
borne RME on upper airway, most found it contributed
to an increase of nasal cavity volume.5,9 However,
conventional tooth-borne RME has side effects such
as buccal crown tipping.10 Additionally, there is limited
skeletal expansion in late adolescence and in adults
because of interdigitation of the midpalatal suture and
adjacent articulations.11 To minimize these undesirable
effects and potential limitations, surgically assisted

DOI: 10.2319/080919-522.1 1 Angle Orthodontist, Vol 00, No 00, 0000

 2 LI, TANG, LIU, LUO, JIANG, MARTIN, GUO
rapid maxillary expansion (SARME) is used, including
surgical release of the closed midpalatal suture.
Several studies have reported an increase of the nasal
cavity volume and poor effect on oropharyngeal
volume after SARME.3,12 Nevertheless, patients tend
to be reluctant to undergo surgical procedures due to
trauma. Recently, mini-implant assisted rapid maxillary
expansion (MARME) for mature patients has been
demonstrated to provide similar skeletal expansion to
SARME, reducing surgical injury and adverse dento-
alveolar side effects.13,14 Increased volume and cross-
sectional area of the nasal cavity have been reported
after MARPE by Kim et al.15
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Because the nasomaxillary complex provides ante-
rior bony support for the upper airway and orthodontic
treatment affects these structures, causing changes in
the airway to some extent, dentists have the respon-
sibility to understand the physiology of upper air-
way.4,5,7,16 Katyal et al.17 found that children with narrow
dentoalveolar transverse width and reduced nasopha-
ryngeal and oropharyngeal sagittal dimensions had a
high risk for sleep-disordered breathing. Many studies
have reported the influence of RME on the upper
The Angle Orthodontist
airway, though the results were different due to various
subjects and expansion methods. However, there are
few studies about changes of each segment of the
upper airway after MARME.
The first aim of this retrospective study was to
compare the dimensions and volume of each segment
of the upper airway before and after MARME in young
adults, including the nasal cavity. The second purpose
was to explore correlations between changes of the
upper airway and vertical skeletal patterns. The
hypothesis was that the dimensions and volume of
the nasal cavity and nasopharynx would be increased
by MARME and vertical skeletal pattern would be
correlated with the results.
MATERIALS AND METHODS
This study included 22 patients (mean age: 22.6 6
4.5 years; range: 18–35 years; four male, 18 female),
who had undergone MARME at the Department of
Orthodontics, Shandong University Dental Hospital,
since January 2017. The study was approved by the
Ethical Commission of Shandong University Dental
Hospital (No. 20190506). All patients provided written
informed consent. The inclusion criteria were: (1)
young adults (18–35 years old) with transverse
maxillary discrepancy, and successful opening of the
midpalatal suture by MARME; and (2) availability of
cone beam computed tomography (CBCT) images
obtained before and after expansion. The exclusion
criteria were: (1) a history of orthodontic or orthognathic
treatment, (2) acute rhinitis during expansion, and (3)
Angle Orthodontist, Vol 00, No 00, 0000
Figure 1. Intraoral view of maxillary skeletal expander and
postexpansion occlusion.
severe craniofacial anomalies or systemic diseases.
To estimate the sample size, a pilot study was
conducted in 10 patients. With a ¼ 0.05, two-tailed,
and a power of 80%, 19 patients were needed.
Every patient was treated by the maxillary skeletal
expansion type II appliance (BioMaterials Korea,
Seoul, Korea) developed by Dr. Moon and colleagues18
(Figure 1). The appliance consisted of bands to the
permanent first molars and four holes for mini-implants.
Orthodontic mini-implants (1.5 mm diameter; 11 mm
length, BioMaterials Korea) were placed at the center
of the holes. After immediate expander activation (four
turns), the expander was activated by two turns every
other day to minimize periodontal damage (one turn ¼
0.13 mm) until maxillary skeletal width was no longer
less than that of the mandible. The required amount of
expansion was set according to the diagnosis and
treatment objective of each patient: usually 32–48
turns. The mean duration of expansion was 38 days
(range: 30–43 days). Mucosal swelling was prevented
by scrupulous oral and nasal hygiene maintenance,
including copious saline irrigation. Medication for
reducing swelling inside the nasal cavity was not
applied. The retention time was at least 3 months,
allowing bone formation in the separated maxillary
suture.
Scan Protocol
CBCT scans (Quantitative Radiology, Verona, Italy;
110 kV, 7.33 mA, 4.8s typical X-ray emission time; 18 3
16 field of view; standard voxel size of 0.3 mm) were
performed before expansion (T0) and after 3 months’
retention (T1) by the same operator. The patients were
scanned in supine position with the Frankfort plane
perpendicular to the floor, keeping the teeth in centric
occlusion and the tongue in the position at the end of
swallowing (against the palate), breathing smoothly,
and no swallowing. The digital imaging and communi-
cations in medicine (DICOM) data were imported into
Dolphin Imaging software (Chatsworth, CA, USA) and
used for the measurements described. The lateral
cephalometric image (LC) before expansion was
measured.
 COMPARISON OF UPPER AIRWAY BEFORE AND AFTER MARME
Figure 2. The orientation of the CBCT images.
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Figure 3. Nasal cavity volume.
The Angle Orthodontist
Figure 4. (A) a. N-ANS, b. ANS-PNS, c. Nasal cross-sectional height
(ANS)(H-ANS), d. Nasal cross-sectional width (ANS)(W-ANS). (B) e.
Nasal cross-sectional height (midpoint) (H-mid), f. Nasal cross-
sectional width (midpoint) (W-mid); (C) g. Nasal cross-sectional height
(PNS) (H-PNS), h. Nasal cross-sectional width (PNS) (W-PNS).
3
Figure 5. (A) Segments of upper airway. The nasopharyngeal airway
volume (V-NPA), Retropalatal airway volume (V-RPA), Retroglossal
airway volume (V-RGA), Hypopharyngeal airway volume (V-HPA).
(B) Height of nasopharyngeal airway (H-NPA), Height of retropalatal
airway (H-RPA), Height of retroglossal airway (H-RGA), Height of
hypopharyngeal airway volume (H-HPA). (C) Minimum cross-
sectional area (MCA).
CBCT Measurements
Before landmark identification, the three-dimensional
volumetric images were oriented with the Dolphin
imaging software as follows: coronal plane (horizontal
line through orbitale bilaterally), sagittal plane (Frank-
fort horizontal), and axial plane (Crista galli to basion)
(Figure 2). The Dolphin software allowed automatic
volume calculation after segmenting the area of
interest by setting the threshold value of 55. Detailed
descriptions of these landmarks and measurements
are shown in Figures 3–8 and Table 1. Lateral
cephalometric measurements according to the Jarabak
analysis are shown in Figure 9.
Statistical Analysis
One examiner performed all measurements. To
estimate reliability of the method, seven randomly
selected patients were re-evaluated after one week.
The intraclass correlation coefficient (ICC) showed
high reliability (0.91, ICC , 0.99). Data normality and
homoscedasticity of variances were assessed by
Shapiro-Wilk and Levene’s tests, respectively. Paired
t-tests were used for continuous matched pairs of
normal data and Wilcoxon signed-rank test for non-
parametric variables. Pearson correlation test was
used to identify correlations if data were normally
distributed; if not, Spearman correlation was used. P ,
.05 was considered statistically significant. SPSS
version 20.0 (SPSS Inc., Chicago, IL, USA) was used
for all statistical analysis.
RESULTS
W-ANS, W-mid, W-PNS, and H-PNS (Table 2, P ,
.001, P , .001, P , .001, P , .001, P ¼ .023) showed
a significant increase, while H-ANS/W-ANS and H-mid/
W-mid (P , .001) decreased. N-ANS increased
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 4 LI, TANG, LIU, LUO, JIANG, MARTIN, GUO
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The Angle Orthodontist

Figure 6. (A) a. Cross-sectional area (PNS) (Area-PNS), b. Latero-lateral distance (PNS)(LL-PNS), c. Anteroposterior distance (PNS) (AP-PNS).
(B) d. Cross-sectional area (uvula) (Area-U), e. Latero-lateral distance (uvula) (LL-U), f. Anteroposterior distance (uvula) (AP-U). (C) g. Cross-
sectional area (epiglottis) (Area-E), h. Latero-lateral distance (epiglottis) (LL-E), i. Anteroposterior distance (epiglottis) (AP-E).

significantly (Table 2, P ¼ .029), while ANS-PNS
decreased (P ¼ .008). In the pharyngeal cross-section
at PNS plane, AP-PNS, LL-PNS, and Area-PNS
showed significant enlargement (Table 2, P ¼ .014; P
¼ .013; P ¼ .011).The V-NC increased by 2925.9 mm3
after expansion (Table 2, P ¼ .014), and the V-NPA
increased by 734.9 mm3 (Table 2, P ¼ .003). No
significant differences in V-RPA, V-RGA, V-HPA, or
minimum cross-sectional area (MCA) were found
before and after MARME (Table 2, P . .05). There
was a significant expansion of nasal, maxillary,
zygomatic, and temporal bone widths (Table 2, P ,
.001; P , .001; P ¼ .018; P , .001).
Enlargement of V-NC showed a positive correlation
with the increase of N-ANS (Table 3, r ¼ 0.426), SGo/
NMe (r ¼ 0.51) and a negative correlation with its
original volume, Sum angle, and ffNSAr (P , .05, r ,
0). The increased V-NPA was closely linked to the
enlarged W-PNS (Table 3, r ¼ 0.655). Most measure-
ments of upper airway were not associated with Sum

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 COMPARISON OF UPPER AIRWAY BEFORE AND AFTER MARME
Figure 7. The measured coronal images for maxillary widths and
palate thickness: coronal line passing though the center of the palatal
root in the most apical region of the maxillary first molars.
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angle, except the original and increased V-NC (Table
4, r ¼ 0.481, r ¼0.608). Area-PNS was highly related
to V-NPA (Table 5, r ¼ 0.592). The enlargement of
Area-PNS correlated positively with the expansion of
maxillary width (HP) (Table 5, r ¼ 0.443). A negative
relationship was found between the expansion of
maxillary width and palate thickness (Table 5, P ,
.05).
The Angle Orthodontist
Figure 8. (A) a. Nasal lateral width; b. Nasal floor width; c. Maxillary
width (NF); d. Maxillary width (HP); e. Palate thickness: the average
thickness of both sides 3mm to the midpalatal suture (3 mm is the
distance from center of holes to the midline of expander). (B) f.
Zygomatic bone width. (C) g. Temporal bone width.
5
Figure 9. 1, SN; 2, SAr; 3, ArGo; 4, GoMe; 5, SGo; 6, NMe; a, ffNSAr,
saddle angle; b, ffSArGo, articular angle; c, ffArGoMe, gonial angle; d,
ffArGoN, upper gonial angle; e, ffNGoMe, lower gonial angle. Sum
angle ¼ ffNSArþ ffSArGo þ ffArGoMe.
DISCUSSION
This study was focused on changes of the vertical
and horizontal dimensions and volume of the upper
airway caused by MARME. Volume of the nasal
cavity and nasopharynx showed significant increas-
es, consistent with some previous studies.4,19 Kim et
al.15 demonstrated that volume of the nasal cavity
increased continuously from pre-expansion to imme-
diately after expansion, and to 1 year after expan-
sion. They reported nasopharyngeal volume showed
a significant increase 1 year after expansion com-
pared with the initial volume.15 In the current study,
volume of the nasal cavity and nasopharynx expand-
ed significantly 3 months after MARME, but it is
necessary to investigate long-term stability in the
future. In addition, the increased nasal osseous width
at the PNS plane contributed to the expansion of
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 6 LI, TANG, LIU, LUO, JIANG, MARTIN, GUO

Table 1. Measurements of Upper Airway and Maxillary, Zygomatic, Temporal Bone

Measurement Definition Reconstruction Figure
Nasal cavity volume (V-NC) Bound by lines connecting the anterior nasal spine (ANS) to the tip 3-dimension 3
of the nasal bone, then to nasion (N), then to sella (S), then to
posterior nasal spine (PNS)
Nasopharyngeal airway volume (V-NPA) The line passing through PNS and S is its anterior border, the line 3-dimension 5
parallel to the Frankfort horizontal plane (FHP) passing through
PNS point is the inferior border, pharyngeal posterior wall is the
posterior border.
Retropalatal airway volume (V-RPA) The line parallel to FHP passing through the tip of the uvula is the 3-dimension 5
inferior border, pharyngeal anterior wall is the anterior border and
pharyngeal posterior wall is the posterior border.
Retroglossal airway volume (V-RGA) The line parallel to the FHP passing through the top of the epiglottis 3-dimension 5
is its inferior border, pharyngeal anterior wall is the anterior
border, and pharyngeal posterior wall is the posterior border.
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Hypopharyngeal airway volume (V-HPA) The line parallel to the FHP passing through the anterior–inferior 3-dimension 5
point of CV4 is its inferior border, pharyngeal anterior wall is the
anterior border, and pharyngeal posterior wall is the posterior
border.
MCA Minimum cross-sectional area of upper airway Axial 5
Nasal cross-sectional height (ANS) (H-ANS) The height of nasal cavity at the cross-section passing through ANS Coronal 4
Nasal cross-sectional width (ANS) (W-ANS) The greatest width of nasal cavity at the cross-section passing Coronal 4
through ANS
Nasal cross-sectional height (midpoint) (H-mid) The height of nasal cavity at the cross-section passing though the Coronal 4
midpoint between ANS and PNS
Nasal cross-sectional width (midpoint) (W-mid) The greatest width of nasal cavity at the cross-section passing Coronal 4
through the midpoint between ANS and PNS
Nasal cross-sectional height (PNS) (H-PNS) The height of nasal cavity at the cross-section passing through PNS Coronal 4
Nasal cross-sectional width (PNS) (W-PNS) The greatest width of nasal cavity at the cross-section passing Coronal 4
The Angle Orthodontist

through ANS
N-ANS The distance between N and ANS Sagittal 4
ANS-PNS The distance between ANS and PNS Sagittal 4
Height of nasopharyngeal airway (H-NPA) The height of nasopharyngeal airway Sagittal 5
Height of retropalatal airway (H-RPA) The height of retropalatal airway Sagittal 5
Height of retroglossal airway (H-RGA) The height of retroglossal airway Sagittal 5
Height of hypopharyngeal airway volume The height of hypopharyngeal airway Sagittal 5
(H-HPA)
Latero-lateral distance (PNS) (LL-PNS) Horizontal line on the greatest latero-lateral dimension at cross- Axial 6
section of pharyngeal airway at the PNS plane
Anteroposterior distance (PNS) (AP-PNS) Vertical line on the greatest anterior-posterior dimension at cross- Axial 6
section of pharyngeal airway at the PNS plane
Latero-lateral distance (uvula) (LL-U) Horizontal line on the greatest latero-lateral dimension at cross- Axial 6
section of pharyngeal airway at the tip of the uvula plane
Anteroposterior distance (uvula) (AP-U) Vertical line on the greatest anterior-posterior dimension at cross- Axial 6
section of upper airway at the tip of the uvula plane
Latero-lateral distance (epiglottis) (LL-E) Horizontal line on the greatest latero-lateral dimension at cross- Axial 6
section of pharyngeal airway at the top of the epiglottis plane
Anteroposterior distance (epiglottis) (AP-E) Vertical line on the greatest anterior-posterior dimension at cross- Axial 6
section of pharyngeal airway at the top of the epiglottis plane
Cross-sectional area (PNS) (Area-PNS) Cross-sectional area of pharyngeal airway at the PNS plane Axial 6
Cross-sectional area (uvula) (Area-U) Cross-sectional area of pharyngeal airway at the tip of the uvula Axial 6
plane
Cross-sectional area (epiglottis) (Area-E) Cross-sectional area of pharyngeal airway at the top of the Axial 6
epiglottis plane
Nasal lateral width The nasal width between the most lateral wall of the nasal cavity Coronal 8
Nasal floor width The nasal width in the level of nasal floor Coronal 8
Maxillary width (NF) The width of maxilla tangent to the nasal floor at its most inferior Coronal 8
level
Maxillary width (HP) The width of maxilla tangent to the hard palate at its most inferior Coronal 8
level
Zygomatic bone width The distance between the foraminula of the left and right zygomatic Axial 8
bone at the axial slice
Temporal bone width The distance between the left and right the inferior border of joint Axial 8
tubercle at the axial slice
Palate thickness The average thickness of left and right sides 3 mm to midpalatal Coronal 8
suture

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 COMPARISON OF UPPER AIRWAY BEFORE AND AFTER MARME 7

Table 2. Changes in the Volumes and Dimensions of the Upper Airway and Changes of Skeletal Widths Before (T0) and After (T1) Mini-Implant-
Assisted Rapid Maxillary Expansion
T0 T1 (T1-T0) (T1-T0) /T0
Parameters Mean (SD) Mean (SD) Mean (SD) Mean (SD) (%) P Value
V-NC, mm 3
18110.7 (6236.8) 21036.5 (4777.8) 2925.9 (4974.6) 16.2 .014*
V-NPA, mm3 5212.1 (1509.9) 5947.1 (2101.6) 734.9 (1045.1) 14.1 .003*
V-RPA, mm3 7477.8 (2901.6) 7903.9 (3001.9) 426.2 (2333.9) 5.7 .485
V-RGA, mm3 4080.1 (1656.4) 4539.5 (2129.2) 459.5 (1549.9) 11.26 .211
V-HPA, mm3 10597.7 (3925.2) 9373.5 (3576.4) 1224.0 (2800.3) 11.6 .053
MCA, mm2 135.0 (55.3) 149.5 (49.8) 14.4 (41.6) 10.6 .053
H-ANS 36.6 (3.5) 37.0 (3.6) 0.4 (1.1) 1.1 .079
W-ANS 19.3 (3.1) 21.5 (3.9) 2.1 (1.4) 10.8 ,.001*
H-ANS/W-ANS 1.9 (0.4) 1.8 (0.4) 0.2 (0.1) 10.5 ,.001*
H-mid 45.4 (4.2) 45.8 (4.4) 0.4 (1.1) 0.9 .082
W-mid 28.0 (5.2) 30.4 (4.7) 2.4 (1.6) 8.6 ,.001*
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H-mid/W-mid 1.7 (0.5) 1.6 (0.4) 0.1 (0.1) 5.9 ,.001*

H-PNS 21.5 (3.9) 21.9 (4.0) 0.5 (1.0) 2.3 .023*
W-PNS 26.1 (2.1) 27.5 (2.8) 1.4 (1.3) 5.4 ,.001*
H-PNS/W-PNS 0.8 (0.2) 0.8 (0.2) 0 0 .124
N-ANS 53.1 (3.1) 53.7 (3.2) 0.6 (1.2) 1.2 .029*
ANS-PNS 46.9 (4.0) 46.2 (4.0) 0.7 (1.1) 1.5 .008*
H-NPA 12.5 (2.1) 12.9 (2.4) 0.4 (1.3) 3.2 .152
H-RPA 29.4 (3.5) 28.6 (3.3) 0.9 (3.1) 2.9 .249
H-RGA 15.6 (5.7) 17.0 (6.3) 1.5 (2.5) 9.7 .01*
H-HPA 27.6 (6.8) 26.3 (6.5) 1.3 (2.5) 4.7 .021*
AP-PNS 17.3 (3.6) 18.0 (3.7) 0.7 (1.3) 4.2 .014*
LL-PNS 26.0 (2.7) 26.9 (3.3) 0.9 (1.5) 3.3 .013*
AP-U 11.9 (3.4) 11.4 (3.1) 0.5 (2.2) 4.5 .28
The Angle Orthodontist

LL-U 19.6 (4.1) 19.9 (3.8) 0.3 (4.2) 1.3 .774

AP-E 11.6 (3.1) 11.6 (3.5) 0 (2.2) 0 1
LL-E 28.5 (4.9) 27.9 (3.6) 0.6 (3.5) 2.2 .400
Area -PNS, mm2 428.6 (126.7) 452.6 (138.6) 24.0 (40.5) 5.6 .011*
Area -U, mm2 202.7 (73.9) 200.9 (87.5) 1.8 (69.3) 0.8 .904
Area -E, mm2 255.7 (105.4) 249.7 (101.1) 5.9 (85.7) 2.3 .746
Nasal lateral width, mm 33.0 (2.5) 35.2 (2.3) 2.3 (1.2) 6.9 ,.001*
Nasal floor width, mm 30.6 (5.8) 32.9 (5.5) 2.3 (1.2) 7.5 ,.001*
Maxillary width (NF), mm 67.6 (5.1) 69.3 (5.1) 1.7 (1.1) 2.5 ,.001*
Maxillary width (HP), mm 65.9 (4.9) 67.9 (5.1) 2.0 (1.0) 3 ,.001*
Zygomatic bone width, mm 100.5 (4.9) 101.0 (5.0) 0.5 (1.0) 0.5 .018*
Temporal bone width, mm 120.1 (6.4) 120.8 (6.4) 0.7 (0.5) 0.6 ,.001*
* Represents a significant correlation, P , .05.

nasopharyngeal volume and the cross-sectional area
of the upper airway at the PNS plane enlarged with
the increase of maxillary width. However, nasopha-
ryngeal volume showed no significant changes in
several previous studies.5 These discrepancies could
be attributed to subject age, differences in definition
of the upper airway volume, the expansion modality,
amount of expansion screw activation, amount of
pierced palatal and nasal cortical bone, skeletal
characteristics, and measurement tools used. The
range of age was also different among studies. In this
study, adults were included with stable upper airways
while others evaluated children,5 growth and devel-
opment also contribute to changes in volume of the
upper airway. According to a previous study, the
upper airway was divided into more segments in this
study, resulting in significant changes.19
No changes were found in volumes of the inferior
section of the upper airway and MCA, in accordance
with the previous results reported.19 Soft tissue plays
an important role in the volume of the upper airway.20
The location and shape of the soft palate might change
due to horizontal expansion of the hard palate. Also,
the position of the tongue may change due to maxillary
width expansion, affecting the volume of the upper
airway to some extent. In the current study, however,
the retention time was so short that soft tissue might
not yet have adapted to the hard tissue. Although the
changes regarding MCA and volume of the hypopha-
ryngeal airway were not significant statistically, there
was still a clinical change observed to some degree. A
long-term study regarding the effect of MARME on the
upper airway is required.
In addition, increased maxillary width was found to
be negatively related to palate thickness, which

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 8 LI, TANG, LIU, LUO, JIANG, MARTIN, GUO

Table 3. Correlation Coefficient Between Significant Changes of such a small sample. Therefore, correlation analysis
Upper Airway Volume and Other Variables was performed. Sum angle showed no link to the
Change of Change of increase of maxillary width, as well as to the
V-NC V-NPA dimensions and volume of each segment of the upper
Original V-NC 0.658* 0.357 airway except nasal cavity volume. The hyperdivergent
Original V-NPA 0.090 0.331 pattern showed less enlargement of the nasal cavity
Change of H-ANS 0.338 0.241
Chang of W-ANS 0.182 0.014
volume, probably because there was a larger original
Change of H-ANS/W-ANS 0.132 0.045 volume in this study, inconsistent with previous
Change of H-mid 0.178 0.160 studies.24 But Sum angle and other nasal measure-
Change of W-mid 0.089 0.297 ments showed no correlations. Turbinates, the nasal
Change of H-mid/W-mid 0.202 0.304 septum, and the condition of the nasal mucosa
Change of H-PNS 0.106 0.065
Change of W-PNS 0.168 0.655* contributed to a complicated nasal structure. There-
Change of H-PNS/W-PNS 0.071 0.371 fore, it was not clear regarding an association between
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Change of N-ANS 0.426* 0.096 changes of the nasal cavity and vertical facial patterns
Change of ANS-PNS 0.295 0.245 in this study. Additionally, only the boundary changes
Change of H-NPA 0.156 0.377
of the upper airway by automated calculation were
Change of AP-PNS 0.087 0.243
Change of LL-PNS 0.035 0.276 measured without its ventilation capacity. Further study
Change of Area -PNS 0.132 0.373 about the morphology and function of the upper airway
Change of nasal lateral width 0.215 0.036 is required.
Change of nasal floor width 0.094 0.068 MARME can improve nasal airflow, leading to better
Change of maxillary width (NF) 0.051 0.010
Change of maxillary width (HP) 0.065 0.138
ventilatory function through increased upper airway
Change of zygomatic bone width 0.072 0.303 volume, though the initial purpose of the procedure
Change of temporal bone width 0.082 0.051 was to correct a narrow maxilla.25 So, it could be a
Palate thickness 0.130 0.028
The Angle Orthodontist

therapeutic option for nasal obstruction.26 However,

SN 0.187 0.131
there was lack of a control group in this study due to
SAr 0.296 0.231
ArGo 0.103 0.062 ethical issues. In addition, the sample size was
GoMe 0.032 0.096 relatively small, and it was not reliable to analyze
SGo 0.204 0.184 measurements in categories according to vertical
NMe 0.455* 0.174 skeletal pattern. The tongue was not at the same
SGo/NMe 0.506* 0.299
ffNSAr 0.537* 0.146
position because of the presence of the expander
ffSArGo 0.034 0.070 before and after MARME. Additionally, the observation
ffArGoMe 0.215 0.143 period was short. In the future, it would be useful to
ffArGoN 0.184 0.083 assess the upper airway after 1 year, and again when
ffNGoMe 0.289 0.209
the expander is removed. Lastly, morphometric chang-
Sum 0.608* 0.298
es would be best related to functional aspects by
* Represents a significant correlation, P , .05. respiratory tests.

indicated that the thicker hard palate showed the larger
resistance. Bony support of the hard palate to mini-
implants was also critical, a more detailed study would
be performed. However, both of them were not directly
related to the increased volume of the nasal cavity and
nasopharynx. The structure of the nasomaxillary
complex and the anatomy of the nasal cavity were
complicated and irregular,21 such as a deviated nasal
septum.22,23 Additionally, there might have been com-
pensatory hypertrophy of the nasal mucosa after
expansion. It was hard to conclude there was any
correlation between amounts of maxillary expansion
and the increase of volume.
There was an attempt made to investigate whether
vertical craniofacial pattern influenced the effect of
MARME on the upper airway. It was not reliable to
analyze the data in categories for clinical study with
CONCLUSIONS
 Transverse dimensions and volume of the nasal
cavity and nasopharynx increased after MARME
when maxillary width increased simultaneously.
Retropalatal, retroglossal, and hypopharyngeal air-
way volume were not found to be changed signifi-
cantly in this study.
 Enlarged nasal width at the PNS plane contributed to
the increase of nasopharynx volume. Enlargement of
maxillary width showed no direct relationship with
increased volume.
 It was unclear regarding the association between
vertical skeletal patterns and changes of upper
airway after MARME because of the complex
structures involved.
 The enlargement of maxillary width by MARME was
affected by hard palate thickness.

Angle Orthodontist, Vol 00, No 00, 0000

 COMPARISON OF UPPER AIRWAY BEFORE AND AFTER MARME 9

Table 4. Correlation Coefficient Between Vertical Skeletal Pattern and Airway, Maxillary Parameters
Sum Sum
Original V-NC 0.481* Change of V-NC 0.608*
Original V-NPA 0.154 Change of V-NPA 0.298
Original V-RPA 0.063 Change of V-RPA 0.260
Original V-RGA 0.235 Change of V-RGA 0.091
Original V-HPA 0.379 Change of V-HPA 0.024
Original H-ANS 0.230 Change of H-ANS 0.264
Original W-ANS 0.205 Chang of W-ANS 0.053
Original H-ANS/W-ANS 0.316 Change of H-ANS/W-ANS 0.018
Original H-mid 0.273 Change of H-mid 0.274
Original W-mid 0.017 Change of W-mid 0.389
Original H-mid/W-mid 0.130 Change of H-mid/W-mid 0.391
Original H-PNS 0.065 Change of H-PNS 0.068
Original W-PNS 0.111 Change of W-PNS 0.149
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Original H-PNS/W-PNS 0.133 Change of H-PNS/W-PNS 0.036

Original N-ANS 0.068 Change of N-ANS 0.323
Original ANS-PNS 0.295 Change of ANS-PNS 0.231
Original H-NPA 0.236 Change of H-NPA 0.141
Original AP-PNS 0.261 Change of AP-PNS 0.158
Original LL-PNS 0.029 Change of LL-PNS 0.212
Original Area-PNS 0.337 Change of Area-PNS 0.258
Original nasal lateral width 0.05 Change of nasal lateral width 0.031
Original nasal floor width 0.223 Change of nasal floor width 0.016
Original maxillary width (NF) 0.12 Change of maxillary width (NF) 0.047
Original maxillary width (HP) 0.115 Change of maxillary width (HP) 0.122
Original zygomatic bone width 0.23 Change of zygomatic bone width 0.158
Original temporal bone width 0.281 Change of temporal bone width 0.065
The Angle Orthodontist

Original palate thickness 0.242

* Represents a significant correlation, P , .05.

Table 5. Other Significant Correlations

Correlation
Variable Variable P Value Coefficient
Original cross-sectional area (PNS) Original V-NPA .004 0.592
Change of cross-sectional area (PNS) Change of maxillary width (HP) .039 0.443
Original palate thickness Change of nasal lateral width .025 0.477
Original palate thickness Change of nasal floor width .001 0.651
Original palate thickness Change of maxillary width (NF) ,.001 0.752
Original palate thickness Change of maxillary width (HP) .001 0.640

ACKNOWLEDGMENTS
We thank Hui Chen for assistance. This work was supported
by key R & D program of Shandong Province [2018GSF118240].
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