International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Rapid maxillary expansion and its consequences on the nasal and

oropharyngeal anatomy and breathing function of children and
adolescents: An umbrella review☆
Arturo Garrocho-Rangel, Miguel Ángel Rosales-Berber, Adriana Ballesteros-Torres,
Zaira Hernández-Rubio, Joselin Flores-Velázquez, Esthela Yáñez-González,
Socorro Ruiz-Rodríguez, Amaury Pozos-Guillén *
Pediatric Dentistry Postgraduate Program, Faculty of Dentistry, University of San Luis Potosí, Mexico

A R T I C L E I N F O A B S T R A C T

Keywords: Objective: To identify, qualify, and summarize the evidence from different systematic reviews about the outcomes
Airway of Rapid Maxillary Expansion (RME) on upper airway dimensions and breathing function in young patients.
Children Methods: A literature search (from 2000 to December 2022) was conducted through PubMed (MEDLINE), the
Evidence-based orthodontics
Cochrane Library, EMBASE, and Dentistry & Oral Science Source. The authors conducted the following umbrella
RME
review phases: research question, study selection criteria (systematic reviews involving randomized clinical trials
and longitudinal observational designs), data extraction, and critical appraisal (bias risk assessment) of selected
articles through the ROBIS tool.
Results: The initial search yielded 65 potential references. After screening titles and summaries, and the elimi­
nation of duplicated publications, 15 articles were eligible for the evaluation of the full-text document. Finally,
11 systematic reviews (5 combined with meta-analysis) were selected, reporting 132 single studies; 38 of them
were unrepeatable. Risk-of-bias assessment showed an average global moderate/high quality among the included
studies. There was high heterogeneity between the systematic reviews’ (and meta-analyses’) methodologies
used.
Conclusions: The present umbrella review concludes that significant and stable increases in the nasal and
oropharyngeal space volumes and a decrease in airway resistance of growing children and adolescents, occur
immediately after RME and at 3, 6- and 12-months follow-up.

1. Introduction respiratory disorders, craniofacial growth, and dental malocclusions [5].

Transverse maxillary deficiency (TMD) is a frequent skeletal and
occlusal condition in children and adolescents, with a reported preva­
lence between 8.5 and 22%, and it is often associated with ante­
roposterior and vertical anomalies (long anterior lower face height,
bilateral maxillary crossbite, high arched palate, low tongue posture,
and incompetent lips), having, as a result, orofacial functional and
aesthetic problems [1–4]. Etiologic factors for TMD during the facial
growth stage include congenital, genetic, developmental, traumatic, and
iatrogenic aspects. Between these, sucking habits and mouth breathing
are well-known contributing issues in children [3].
Dentistry literature has widely evidenced a close association between
Adequate nasal breathing in children is essential to ensure the proper
maturing of the craniofacial complex [6]. Dysfunctional nasal breathing
is due to different pathologies, such as allergic rhinitis, adenoid or tonsil
hypertrophy, nasal septum deviation, among other conditions [4,7].
This condition has been frequently associated with open mouth,
maxillary narrowing or constriction, posterior crossbite, high palatal
vault, and subsequent rising of the nasal floor and airway space reduc­
tion [8,9]. Furthermore, TMD has been considered a potential anatomic
etiological factor for a condition known as obstructive sleep apnea in
children [4].
Rapid maxillary expansion (RME) is a technique in orthodontics that
provides considerable transverse skeletal effects. This approach has been

☆
The present umbrella review was registered in PROSPERO (CRD42022320105).
* Corresponding author. Pediatric Dentistry Postgraduate Program, Faculty of Dentistry, University of San Luis Potosí, San Luis Potosí, Mexico.
E-mail address: apozos@uaslp.mx (A. Pozos-Guillén).

https://doi.org/10.1016/j.ijporl.2023.111633
Received 5 March 2023; Received in revised form 3 June 2023; Accepted 11 June 2023
Available online 23 June 2023
0165-5876/© 2023 Elsevier B.V. All rights reserved.
A. Garrocho-Rangel et al.
generally recognized as an early orthodontic/orthopedic therapy for
children and adolescents suffering from TMD [7]. The central clinical
aim is to open the midpalatal suture, rendering an appropriate and
stable width of the maxilla [10]. The suture continues unclosed until the
age of 12 approximately when new ossified tissue is formed [5,8,10].
RME is performed by placing a fixed orthodontic device with a laterally
progressive opening system, using a daily activated screw [5,11]. This
procedure has shown beneficial results on the surrounding regions,
expanding the nasal and oropharyngeal airway dimensions and func­
tion, and enhancing nasal breathing function in the medium and long
term, because of the anatomical proximity of the oral cavity and the
upper airways [5,8,12,13]. Given the bones of the maxilla constitute an
important part of the structure of the nasal cavity, as long as the mid­
palatal suture remains unclosed the nasal cavity walls are also laterally
moved and the palatal vault lowered, reducing thus the nasal and
oropharyngeal airway obstruction and enabling a better airflow passage
[7,10,11,14]. Both zygomatic and sphenoid bones of the cranial base
exhibit significant opposition to palatal expansion. As a consequence,
the splitting of maxillary bones occurs in a triangular way, in which the
principal enlargement is observed at the incisor level, just beneath the
nasal cavity valves [15]. This process results in a wider anterior than
posteriorly, which provides more favorable conditions for the nasal
cavity and also the breathing pattern [1,16,17].
The current umbrella review aimed to provide low-biased compre­
hensive evidence from systematic reviews about the therapeutic efficacy
and dimensional changes of RME on the nasal and oropharyngeal
structures in young patients, in terms of airflow permeability, evaluating
also the immediate and long-lasting effects.
2. Materials and methods
2.1. Design and research question
The present umbrella review was registered in PROSPERO and fol­
lowed the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines [18]. It also applied the fundamental
principles for umbrella reviews emitted by the Joanna Briggs Institute
(JBI) [19] and The Cochrane Collaboration [20]. A comprehensive
methodological protocol was previously designed by all authors. This
study asked the following PECO question: In children and adolescents,
are there significant changes in the nasopharyngeal anatomical struc­
tures when comparing pre-and post-RME therapy outcomes?
2.2. Eligibility criteria
The criteria for article inclusion were: systematic reviews with or
without meta-analysis, published after the year 2000; studies performed
on human beings under 18 years old; and outcome assessments of fixed
RME appliances that occurred in the specific anatomic area of interest.
The exclusion criteria were: dual publication; narrative or scoping re­
views; also reviews involving surgically assisted RME, RME in
conjunction with other treatment (orthodontic/orthopedic) strategies
(for example, when mini-screws were employed for assisting RME), and
patients with cleft lip/palate or with craniofacial and/or neurological
genetic syndrome diagnosis.
2.3. Search strategy and study selection
Four electronic databases served for the screening of potential ref­
erences: PubMed (MEDLINE), The Cochrane Database of Systematic
Reviews, EMBASE, and Dentistry & Oral Science Source (EBSCO); un­
published or gray literature was not explored. The following primary
concepts were introduced: “rapid maxillary expansion” AND “nasal
airway” AND “breathing OR respiratory disorders” AND “children and
adolescents” AND “systematic reviews and meta-analyses”; these con­
cepts were combined with synonyms, keywords, and MeSH (subject
2
International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633
headings) terms.
This search strategy was adapted to the different databases. The
search was restricted to the English language and for articles published
between January 2000 and December 2022. The bibliography of each
selected study was also carefully hand-reviewed. This screening process
was independently performed by three experienced researchers (AYBT,
ZJHR, and YFV). Any disagreement was resolved by discussion until
reaching a consensus. Potential eligible articles were then retrieved in
full-text form for a critical assessment.
2.4. Data collection
Data from all finally included articles were independently and
separately extracted and recorded by the other three authors (MSRR,
MEYG, and MARB), using a predesigned and prepiloted extraction form.
The collected data included the first author, publication’s year and
country, the total number of included studies and participants, publi­
cation date range of included studies, systematic review methodology
(search strategy and databases, type of included studies, risk of bias
assessment tool, follow-up length, and conduction or not of a meta-
analysis), sample characteristics, type of RME appliance, and main
outcomes/findings. Again, in the case of any discrepancy between re­
viewers, a consensual agreement was reached by discussion.
2.5. Evaluation of methodological quality and risk of bias
Two experienced researchers (JAGR and AJPG) made use of the
ROBIS tool [21] to perform an assessment of the methodological quality
and risk of bias of the selected articles. This tool comprises four broad
categories: intervention, diagnosis, prognosis, and etiology. The
completion of the following three stages is required for the assessment
process: (i) evaluating the relevance of the review with questions
relating to interventions, (ii) recognizing those concerns related to the
review conduction, according to four areas [study eligibility criteria (5
items), study identification and selection (5 items), data collection and
review valuation (5 items), and synthesis and conclusions (6 items)];
and (iii) assessing the risk of bias (3 items); every item is answered as
“Yes”, “Probably Yes”, “Probably No”, “No”, and “No Information”, with
“Yes” indicating low concern. The resultant level of bias hazard associ­
ated with each domain is then graded as “low”, “high”, or “unclear”. The
overall risk-of-bias score for every study has three grades: “low”, “high”,
and “unclear” [22–24]. The inter-agreement value was determined by
Cohen’s Kappa statistics (k = 0.93). Scoring discrepancies were solved
by debate until a concordance was obtained.
3. Results
The initial search yielded 65 potential systematic reviews. After
screening titles and abstracts, and the duplicates, 15 articles were
eligible for full-text assessment. Finally, 11 systematic reviews (pub­
lished between 2009 and 2021; 5 combined with meta-analysis) were
selected for the current umbrella review (see the flowchart of study
selection, Fig. 1). These reviews comprised in total of 33 unique single
articles (the vast majority were randomized clinical controlled trials);
and included 4022 participants in total. Two RME systematic reviews
were excluded because they were not specific to upper airway changes
[25,26]; and two others, in which RME was applied simultaneously with
other orthodontic/orthopaedic devices (e.g., miniscrew-assisted RME
[13] or maxillary protraction [27]). Table 1 describes the main char­
acteristics of the selected systematic reviews; according to this infor­
mation, there was considerable variability in the reported
methodologies in each included review. Risk-of-bias assessment through
the ROBIS tool (Table 2) showed an average global moderate/high
quality (risk of bias) among the included studies [1,3–7,10–12,14].
Table 3 summarizes the results of the different included meta-analyses.
Globally, the selected systematic reviews aimed to measure the
A. Garrocho-Rangel et al.
Fig. 1. PRISMA flow chart for literature search.
changes in airway dimensions (area or volume), and function (breathing
resistance) in the nasal and oropharyngeal areas, through different nasal
airway diagnostic techniques (e.g., computed rhinomanometry, acoustic
rhinometry), 2D radiographs (cephalometric analysis) or 3D imaging
(magnetic resonance imaging, conventional computed tomography,
cone-beam computed tomography, and digital photogrammetry), before
and after the RME procedure in pediatric patients with or without upper
airway (breathing/respiratory) disorders.
4. Discussion
Clinicians should thoroughly consider the information based on the
literature evidence throughout the decision-making of clinical problems
through the highest levels of published evidence, such as systematic
reviews, meta-analyses, and umbrella reviews -the overview of existing
systematic reviews- [28]. Systematic reviews with meta-analysis are
considered the superior level of evidence-based oral health research, and
each review possesses an individual methodological quality according to
diverse concerns. According to this, the main focus of umbrella reviews
is to deliver an ample outlook of the best information associated with a
specific issue and bring into focus where the evidence is consistent, or if
incongruent or conflicting findings exist, and exhibit and detail the
reasons why [19,23]. With the increase of published and available sys­
tematic reviews and meta-analyses in pediatric dentistry as well as in
orthodontics and craniofacial orthopedics, a logical next step during
clinical research is to offer the evidence obtained from these compre­
hensive reviews. So, an umbrella review only considers the selection of
the most transcendent evidence. This type of review provides a bird’­
s-eye view of those discoveries for specific clinical issues or phenomena.
It also allows the assessment and consideration of whether independent
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International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633
reviewers address similar clinical questions, examine similar outcomes,
and reach the same conclusions [29]. Thus, the present summarized
overview was structured from systematically and critically appraised
published systematic reviews, to establish how best to translate the ev­
idence about the revised topic into clinical practice and to suggest
available references for future research.
Maxillary or palatal expansion is a very commonly used therapy
approach for the improvement of skeletal narrowing or constriction of
the maxilla, increasing its transverse width through the opening of the
midpalatal suture [30–32]. This orthodontic/orthopedic procedure can
be achieved using different expansion rates (rapid or slow) and forces
employing diverse appliances; the appropriate choice among these al­
ternatives can influence the clinical treatment outcomes and the po­
tential relapse [31]. Therefore, we intended to address the present
clinical topic through a systematic appraisal of the evidence, using a
transparent methodology; regardless of its positive qualities, this um­
brella review still exhibits some constraints. One concern was the vari­
ability among the research designs of the included studies in the current
review, namely randomized and controlled clinical trials,
non-randomized (before-after) trials, prospective cohorts, or retrospec­
tive case-control studies, which are more or less prone to different
methodological biases. Another shortcoming to consider is the homo­
geneity among the pooled data from the eligible systematic reviews. In
the current overview, the observed high heterogeneity made the per­
formance of an overall quantitative/statistical analysis impossible given
the very different methodological designs employed, the tools or scales
for assessing the quality of eligible individual articles, and some re­
strictions during the study selection (e.g., language, publication date,
format, or sample size) [31]. Furthermore, an extensive variability could
be observed in the number of selected articles in the systematic reviews,
A. Garrocho-Rangel et al. International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633

Table 1
Data charting of included systematic reviews.
First author, Total number Publication Methodology Sample Type of RME Measurement Main outcomes/findings
country, and of studies date range of characteristics appliance technique (s)
year and included
participants studies

Gordon et al. - 4 1900–2008 - Databases: ML, EMB, - Healthy - Hyrax. - AR for MCA. - Significant increase in
(Canada), - 202 CDSR, ACPJC, DARE, children with - Haas. MCSA.
2009 [14] CCTR, LIL, SCP, and transverse - Small changes in NCV
TIWoS. maxillary and ND.
- Hand search. deficiency.
- RCCTs only. - 4–14.1 yrs old.
- RBAT: Lagravère et al.25
- F–U: NR.
- M-A: No
Baratieri et al. - 8 1900–2010 - Databases: Ovid ML, SC, - Children with - Hyrax. - RMN, AR, - NCV increase.
(Brazil), - 260 SCP, VHL, and CochL. transverse posteroanterior and - Decreased
2011 [10] - Hand search. maxillary lateral Rx, and CBCT. craniocervical
- RCCTs only. deficiency. angulation with
- RBAT: Lagravère et al.25 - 7–16 yrs old. increases in posterior
- F–U: 6 months to 5 yrs. nasal space.
- M-A: No. - Reduction of NAR and
TNF.
- Increase of MCSA.
Aziz et al. - 2 1974–2015 - Databases: Ovid ML, - Children with - Hyrax. - Frontal - Significant
(Canada), - 110 EMB, TIWoS, CDSR, decreased nasal posteroanterior straightening of the
2015 [1] CCTR, CMR, DARE, breathing due cephalogram. nasal septum in the
ACPJC, and NHSEED. to nasal septum middle and inferior
- Hand search. deviation. thirds of the nasal
- RCCTs only. - 5–17 yrs old cavity.
- RBAT: MINORS. - Better results in
- F–U: 12 weeks to 6 children than in
months. adolescents.
- M-A: No. - A second study
reported no positional
change in the nasal
septum.
- However, both studies
exhibited some
methodological
limitations.
Buck et al. - 22 1946–2016 - Databases: ML (all - Children under - Hyrax. - AR, 3D Rx, and - Significant increase of
(Australia/ - 538 versions), EMB, CCRC, RME treatment. - Haas. digital TAV from baseline.
Germany/ ISRCTN registry, and - 7.5–14.5 yrs photogrammetry.
Greece), unpublished literature. old.
2017 [7] - Hand search.
- RCCTs, non-randomized
trials, and cohort
studies; each study with
at least 8 patients.
- RBAT: Cochrane
Collaboration.
- F–U: 8 months.
- M-A: Yes.
Di Carlo et al. - 9 2005–2016 - Databases: ML, Ovid, - Children with - Hyrax. - CBCT. - Contradictory or
(Italy), 2017 - 244 and CochL. maxillary - Haas. inconsistent results
[8] - Hand search. transverse - McNamara. regarding head
- RCCTs and deficiency. posture, tongue
observational studies. - 7.8–16 yrs old. position, and NCV.
- RBAT: Cochrane
Collaboration.
- F–U: NR.
- M-A: No.
Lee et al. - 9 2000–2016 - Databases: PubMed, ML, - Children with - Hyrax. - Cephalometric Rx - Significant changes in
(Taiwan), - 221 SD, and TIWoS. maxillary - Haas. (anteroposterior the upper airway and
2017 [12] - Hand search. transverse - Some studies linear changes) and nasal passage airway.
- RCCTs only. deficiency. included CBCT. - Non-significant
- RBAT: Newcastle- - 6–16 yrs old. facemask changes in the lower
Ottawa scale. protraction airway and the airway
- F–U: 6 months–2.5 yrs. appliances. * below the palatal
- M-A: Yes. plane.
Alyessary et al. - 20 2005–2016 - Databases: TIWoS, - Children with - Hyrax. - RMN, CBCT, - Non-surgical RME
(Malasya/ - 455 D&OSS, and PubMed. maxillary - Haas. conventional improved nasal
Irak/ - Hand search. transverse tomography, and Rx. breathing.
Singapore), - RCCTs and deficiency. - Increase of NC
2019 [3] retrospective/ - 7–15 yrs old. geometry.
- Decrease of NAR.
(continued on next page)

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A. Garrocho-Rangel et al. International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633

Table 1 (continued )
First author, Total number Publication Methodology Sample Type of RME Measurement Main outcomes/findings
country, and of studies date range of characteristics appliance technique (s)
year and included
participants studies

prospective cohort
studies.
- RBAT: NR.
- F–U: NR.
- M-A: No.
Calvo- - 12 1980–2020 - Databases: PubMed ML, - Children with - Hyrax. - RNM. - Significant reduction of
Henriquez - 301 EMB, CochL, SCP, SD, maxillary - Haas. NAR.
et al. Scielo, and Trip. transverse - McNamara. - Significant increase in
(France/ - Hand search. deficiency. TNF.
Spain/USA/ - RCCTs, prospective/ - 7–13 yrs old.
Portugal), retrospective cohort
2020 [6] studies, and case-report
series, published in peer-
reviewed journals.
- RBAT: Lagravère et al.25
- F–U: 0–30 months.
- M-A: Yes.
Niu et al. - 24 1946–2019 - Databases: ML, EMB, - Children with - Hyrax. - CT, CBCT, and MRI. - Immediately after
(Denmark/ - 700 CCRC, unpublished and maxillary - Haas. RME: Significant
Italy), 2020 gray literature. transverse - McNamara. increase of
[4] - Hand search. deficiency. nasopharynx and
- RCCTs, non-randomized - 7–15 yrs old. oropharynx.
trials, and cohort - Three months later: NC
studies. and nasopharynx
- RBAT: Cochrane showed a significant
Collaboration; and a volume increase.
customized tool
developed for non-
randomized trials (based
on the Newcastle-
Ottawa scale and
empirical evidence of
bias in orthodontic clin­
ical research).
- F–U: 3–12 months.
- M-A: Yes.
Sakai et al. - 18 2003–2019 - Databases: Ovid ML, - Children with - Hyrax. - CT, Rx - In the short term, RME
(Brazil), - 887 EMB, and SCP. mouth - Haas. (teleradiography and promotes the
2021 [11] - Hand search. breathing. frontal enlargement of the
- RCCTs and cohort - 5–14.7 yrs old. posteroanterior dental arches and the
studies. radiography), AR, nasal and maxillary
- RBAT: Fowkes & and computed RMN. structures, thus
Fulton’s guidelines. improving mouth
- F–U: 0–30 months. breathing.
- M-A: No.
Santana et al. - 4 1980–2020 - Databases: PubMed, LIL, - Children with - Hyrax. - Cephalometric Rx - Increase in the
(Brazil), - 104 EMB, SCP, TIWoS, mouth - Haas. and CT. transverse dimensions
2021 [5] CochL, and gray breathing and/ of the maxilla and the
literature. or obstructive upper airway volumes,
- Hand search. respiratory 3 months after RME.
- RCCTs, non-randomized disorders. - However, the quality of
trials, and case-series - Up to 14 yrs evidence from the
reports. old. articles included was
- RBAT: ROBINS-1 and considered very low.
GRADE.
- F–U: 3–30 months.
- M-A: Yes.

Abbreviatures: ML = Medline. EMB = Embase. CDSR=Cochrane Database of Systematic Reviews. ACPJC=American College of Physicians Journal Club. DARE =
Database of Abstracts of Reviews of Effects. CCTR=Cochrane Central Register of Controlled Trials (CENTRAL). CMR=Cochrane Methodology Register. LIL = Lilacs.
SCP=Scopus. SD=Science Direct. TIWoS=Thomson’s ISI Web of Science. SC=Scirus. VHL=Virtual Health Library. CochL = Cochrane Library. HTA=Health Tech­
nology Assessment. NHSEED=NHS Economic Evaluation Database. D&OSS = Dental & Oral Science Source. RCCT = Randomized Clinical Controlled Trials. RBAT =
Risk of bias assessment tool. F–U=Follow-Up. NR=Not reported. M-A = Meta-Analysis. AR=Acoustic rhinometry. RMN=Rhinomanometry. Rx = Radiography.
CBCT=Cone-beam computed tomography. MRI = Magnetic resonance imaging. MCSA = Minimum cross-sectional area. NCV=Nasal cavity volume. ND=Nasal di­
mensions. NAR=Nasal airway resistance. TNF = Total nasal flow. TAV = Total airway volume.
* Only those data from the RME without facemask group were extracted.

ranging from only two up to 24, even when similar interventions, pur­
poses, and results were assessed. The presence of overlapping studies
across the systematic reviews was also notorious; this means that
repeated articles appeared several times, which would have had unin­
tentionally a larger influence on the meta-analysis [22]. Finally, some
included studies lacked control groups.
On the other hand, the different chosen orthodontic/orthopedic
strategies, endpoints, control groups, and outcome measures in each
selected systematic review also influenced this heterogeneity and hin­
dered the synthesis of results [22]. There were evident differences

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A. Garrocho-Rangel et al. International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633

Table 2
Critical review of included systematic reviews.
Systematic review Study eligibility Identification and selection of Data collection and study Synthesis and Risk of bias in the
criteria studies appraisal findings review

Gordon et al. [14] Low risk Low risk Low risk Low risk Low risk
Baratieri et al. [10] Low risk Low risk Low risk Low risk Low risk
Aziz et al. [1] Low risk Low risk Unclear risk Low risk Unclear risk
Buck et al. [7] Low risk Low risk Low risk Low risk Low risk
Di Carlo et al. [8] Low risk Low risk Low risk Low risk Low risk
Lee et al. [12] Low risk Low risk Low risk Low risk Low risk
Alyessary et al. [3] Low risk Low risk Low risk Unclear risk Low risk
Calvo-Henriquez et al. Low risk Low risk Low risk Low risk Low risk
[6]
Niu et al. [4] Low risk Low risk Low risk Low risk Low risk
Sakai et al. [11] Low risk Low risk Low risk Low risk Low risk
Santana et al. [5] Low risk Low risk Low risk Low risk Low risk

Table 3
Summary of quantitative results from retrieved meta-analyses.
MA Measurement Mean difference (95%IC) Statistical significance

Lee et al. [12]
Buck et al. [7]
Niu et al. [4]
Calvo-Henriquez et al. [6]
Santana et al. [5]
Upper airway (anteroposterior linear changes in mm) PNS - AD1 (FMP + RME vs. Ctrl)
PNS - AD2 (FMP + RME vs. Ctrl)
ST1 (RME vs. Ctrl)
Lower airway (anteroposterior linear changes in mm) ST2 (RME vs. Ctrl)
Total airway volume mean increase (mm3) IA RME
ARP
Nasal cavity volume mean increase (mm3) IA RME
ARP
Nasopharyngeal volume mean increase (mm3) IA RME
ARP
Oropharyngeal volume mean increase (mm3) IA RME
ARP
Nasal airway resistance mean reduction (Pa s/cm3) Quasi-experimental studies
Controlled trials
Nasal airflow mean increase (cm3)
Nasal volume increase (mm3)
Oropharyngeal volume increase (mm3)
Internasal distance (mm)
1.63 (− 0.14, 3.39) NS
2.68 (0.37, 5.0) S (in favor of FMP + RME)
0.80 (0.19, 1.41) S (in favor of FMP + RME)
− 0.20 (− 0.68, 0.28) NS
1218.3 (701.97, 1734.63) S (in favor of RME)
1143.87 (698.85, 1590.9) S (in favor of RME)
1224 (− 278, 2725) NS
1604 (891, 2318) S (in favor of RME)
829 (441, 1217) S (in favor of RME)
492 (70, 913) S (in favor of RME)
1424 (197, 2651) S (in favor of RME)
578.62 (− 301.45, 1458.7) NS
0.12 (0.06–0.18) S (in favor of RME)
0.02 (− 0.01, 0.07) NS
29.9 (9.17, 50.64) S (in favor of RME)
3.0 (− 0.25, 6.25) NS
2.18 (0.98, 3.38) S (in favor of RME)
1.79 (0.95, 2.62) S (in favor of RME)

MA = Meta-analysis. PNS = Posterior nasal spine. PNS-AD1 = Distance between PNS and the nearest adenoid tissue measured through PNS-Ba (Basion) line. PNS-AD2
= Distance between PNS and the nearest adenoid tissue measured through a perpendicular line to S–Ba from PNS. ST1 = Shortest distance 1; the minimum distance
between the upper soft palate and the nearest point on the posterior pharyngeal wall. ST2 = Shortest distance 2; the minimum distance between the point where the
posterior tongue contour crosses the mandible and the nearest point on the posterior pharyngeal wall. FMP = Facemask protraction. IA = Immediately after. ARP =
– No significant. S = Significant.
After retention period. Ctrl = Control group. NS–

among individual studies regarding the RME protocols: active treatment
length (from 28 or 30 days up to 6 weeks), type of appliance, screw
activation schemes (e.g., 1 or 2 turns per day, or 4 turns on the first day
and subsequently 2 turns each day, or 1 turn every other day), amounts
of maxillary/palatal expansion, and period of retention after the active
phase or follow-up times (0 up to 5 years). There were also differences in
the type of outcome measurement (clinical, radiographical, cephalo­
metric, or by imaging); regarding this issue, the upper airway anatom­
ic/volumetric, and breathing pattern/function changes after RME
treatment have been traditionally evaluated by using different
measuring techniques for a more reliable quantification on the breathing
performance; these techniques include acoustic rhinometry, cephalo­
metrics and other 2D x-rays, 3D imaging, and polysomnography, among
others [33]. Another source of heterogeneity was the study sample
characteristics: the range of the basal age (in some cases the treatment
started at the age of 5), and the inclusion of healthy subjects or with
respiratory disorders. Additionally, data from Hyrax, Haas, and other
RME appliances were incorporated. Even when pooling collected in­
formation from diverse RME modalities presents superior evidence,
clinicians should consider that it can hinder the applicability of the
outcomes or findings in the clinical setting since the therapies may differ
in biomechanics and provide different effects [31]. Despite all of these
concerns, we have attempted in the next sections to summarize the re­
sults and findings of the thirteen selected systematic reviews.
The main findings reached about upper airway amplitude and
breathing behavior in children and adolescents after RME treatment
were as follows. There were increases in (1) the nasal cavity volume/
width/dimensions (between 2.0 and 2.5 mm); (2) the minimal cross-
sectional area (according to the distance from the nostril into the
nasal cavity, visually measured); however, it was not clinically signifi­
cant; (3) the posterior nasal space (from the posterior nasal spine to the
basion area, or the area of the nasal valve and the inferior nasal concha)
or oropharyngeal space (up to 5.3 mm); and (4) a considerable align­
ment of the nasal septum and a positive effect in its asymmetry, but only
during childhood stage (however, individual studies for this condition
showed serious methodological limitations) [1]. As a result, the nasal
flow/breathing improved and the nasal airway resistance was reduced.
The best RME outcomes occurred before the fusion of the medial palatal
suture was established [11]. Some of these favorable changes were
stable in the long term (11–60 months) after RME [10]; however,
long-term effects could not be assessed in two studies [4,11]. In this
regard, it should be considered that due to the complexity of upper
airway anatomy and function, the diverse measuring techniques
employed across the studies had distinct purposes and could comple­
ment each other to value the actual breathing variations after RME [10].
In the current umbrella review, five different systematic reviews/
meta-analyses contributed to the overall evidence summary [4–7,12].
These conducted meta-analyses were considered adequate because they
met the methodological and statistical criteria for the combined data
analysis, for example, the measurement of heterogeneity among the

6
A. Garrocho-Rangel et al.
original studies (Q and/or I2 tests), the construction of forest plots for
the magnitude of the observed effects, and the reporting of pooled es­
timates (e.g., mean differences or weighted mean differences) with their
corresponding 95% confidence-interval calculation, by using the fixed-
and/or random-effect models, to satisfactorily account for the diverse
RME modalities, patient characteristics, upper airway regions, and
measurement techniques [4,7]. Publication bias (funnel plot and Egger’s
regression) and sensitivity analyses were also detected. The data sum­
mary of retrieved meta-analyses is detailed in Table 2 [4–7,12].
Treatment of transverse maxillary deficiencies has largely been
related to breathing problems and discussed by pediatric dentistry
practitioners, orthodontists, and otolaryngologists because of the close
anatomical relationship between the oral and nasopharyngeal spaces.
Several studies have demonstrated the nasal width increasing above the
expanded mid-palatal suture. In this regard, maxillary hypoplasia or
constriction has been recognized as a risk factor for obstructive sleep
disorders (snoring, and adenoid or tonsil hypertrophy) in children and
adolescents and is considered the most important influence associated
with therapeutic failure in the adenotonsillectomy procedure [5].
Further, in a small prospective cohort study by Guilleminault et al. [34]
that included sick children, enlarged tonsils and narrow maxillary
complex were successfully treated with either adenotonsillectomy fol­
lowed by RME, as a complementary procedure, or contrariwise; both
procedures were required to obtain an adequate apnea-hypopnea index.
In this same regard, and according to different studies [35,36], RME has
been associated with an enhancement in the quality of life of young
patients at high risk of sleep respiratory anomalies. However, RME
should not be recommended as a first-election therapeutic modality for
children or adolescents with nasal breathing disorders or decreased
airway dimensions without a carefully well-indicated orthodontic pur­
pose (e.g., maxillary transversal deficiencies) [10,14].
Finally, and from a pediatric otolaryngologic point of view,
specialized practitioners should be aware of the indications and benefits
of the RME procedures, particularly in young children, before the medial
maxillary suture is fully closed, typically into the teenage years. For
instance, according to Camacho and coworkers [37], RME could be
considered as a primary treatment option in pediatric patients with high
and/or narrow hard palate and with small tonsils; or as a secondary
intervention in patients who have failed adenotonsillectomy and persist
with obstructive sleep apnea. In this same context, practitioners also
should contemplate other potential favorable effects or implications in
other body regions of this orthodontic intervention, such as the middle
ear and Eustachian’s tube function, enuresis, speech, and obstructive
sleep apnea [38]. Pediatric otolaryngologists’ involvement in a clinical
multidisciplinary team, which also includes orthodontists and pediatric
dentists, is always recommended when RME treatment is planned.
5. Conclusions
The present umbrella review concludes that significant and stable
increases in the nasal and oropharyngeal space volumes and a decrease
in airway resistance of growing children and adolescents, occur imme­
diately after RME and at 3, 6- and 12-months follow-up.
Ethical approval
Not Applicable.
Funding
Not Applicable.
Informed consent
Not Applicable.
7
International Journal of Pediatric Otorhinolaryngology 171 (2023) 111633
Author’s contribution
All the authors confirm their participation to this study. Arturo
Garrocho-Rangel, Miguel Ángel Rosales-Berber and Amaury Pozos-
Guillén participated in conceptualization; Adriana Ballesteros-Torres,
Zaira Hernández-Rubio, Joselin Flores-Velázquez, Esthela Yáñez-
González and Socorro Ruiz-Rodríguez contributed to Methodology and
Investigation; Arturo Garrocho-Rangel, Miguel Ángel Rosales-Berber,
Adriana Ballesteros-Torres and Zaira Hernández-Rubio performed
Writing-Original Draft, and performed final Writing-Review & Editing.
All authors agree with the manuscript.
Declaration of competing interest
No conflict of interest.
Acknowledgments
The authors wish to thank Ms. Ilse Garrocho-Cortés for her valuable
participation in the writing and editing of this manuscript.
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