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DentalPressJOrthod.2014JanFeb19(1):2635.

PMCID:PMC4299416

doi:10.1590/21769451.19.1.026035.oar

Language:English|Portuguese

Anassessmentofthemaxillaafterrapidmaxillaryexpansionusingconebeam
computedtomographyingrowingchildren
JessicaL.Woller, 1KiBeomKim, 2RolfG.Behrents, 3andPeterH.Buschang4
1
Formerresident,DepartmentofOrthodontics,CenterforAdvancedDentalEducation,SaintLouisUniversity.
2
Assistantprofessor,DepartmentofOrthodontics,SaintLouisUniversity.
3
Professor,HeadoftheDepartmentofOrthodontics,SaintLouisUniversity.
4
Adjunctprofessor,DepartmentofOrthodontics,SaintLouisUniversityandBaylorUniversity.
Contactaddress:KiBeomKim.Email:kkim8@slu.edu
Received2011Jan27Accepted2011May3.
Copyright2014DentalPressJournalofOrthodontics
ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNonCommercialLicense,whichpermitsunrestrictednon
commercialuse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

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Introduction

Withtheadventofconebeamcomputedtomography(CBCT),itisnowpossibletoquantitativelyevaluatethe
effectsofrapidmaxillaryexpansion(RME)ontheentiremaxillarycomplexingrowingpatients.
Objective

Thepurposeofthisstudyistousethreedimensionalimagestoevaluatethedisplacementthatoccursatthe
circummaxillarysutures(frontonasal,zygomaticomaxillary,intermaxillary,midpalatal,andtranspalatalsutures)
followingrapidmaxillaryexpansioningrowingchildren.
Methods

TheCBCTscansof25consecutivelytreatedRMEpatients(10male,15female)withmeanageof12.32.6
years,wereexaminedbeforeexpansionandimmediatelyfollowingthelastactivationoftheexpansionappliance.
Results

Statisticallysignificant(P<0.05)amountsofseparationwerefoundforthedisplacementofthebonesofthe
frontonasalsuture,theintermaxillarysuture,thezygomaticomaxillarysutures,andthemidpalatalsuture.The
changeinangulationofthemaxillaryfirstmolarsduetoRMEwasalsostatisticallysignificant.Therewasno
statisticallysignificantdisplacementofthetranspalatalsuture.
Conclusions

Rapidmaxillaryexpansionresultsinsignificantdisplacementofthebonesofcircummaxillarysuturesingrowing
children.
Keywords:Palatalexpansiontechnique,Orthodontics,Conebeamcomputedtomography,Cranialsutures
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INTRODUCTION

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Rapidmaxillaryexpansion(RME)isthemostcommonorthopedicprocedureusedtocorrectamaxillawith
transversediscrepancy.Heavyorthopedicforcesareusedtoseparatethetwohalvesofthemaxillaatthemidpalatal
suture.1IndicationsforRMEincludetheneedtocorrectposteriorcrossbiteandtoincreasearchperimeterin
patientswithatoothsizearchlengthdeficiencytoaddresscrowding.2,3
Alongwiththeopeningofthemidpalatalsuture,4,5RMEhasaneffectontheentiremaxillarycomplex.69
AccordingtoStarnbachetal,10palatalexpansiondoesnotonlyseparatethemidpalatalsuture,butthe
circumzygomaticandcircummaxillarysuturalsystemsaswell.Specifically,thenasal,thezygomaticomaxillary,and
thezygomaticotemporalaresomeofthesuturesaffectedbyRME.Studiesemployingdryskulls,7rhesus
monkeys1114andfiniteelementmodels(FEM)15,16,17haveprovedthesesuturestobeaffected,butthe
descriptionstendtobequalitativeinnature,exceptforthestresslevelscalculatedbytheFEMstudies.
Whiletherearesignificantcontributionsfromallofthesepaststudies,thereareweaknessesassociatedwitheach
typeofstudymentionedabove.StudiesondryskullslackthesofttissuesthatcanhampertheeffectsofRME,
particularlytheconnectivetissuethatformsthesuturebetweenbones.Rhesusmonkeyshaveasignificantly
differentmaxillaryanatomyincomparisontohumans.ThebiggestproblemFEMfacesisthefactthatthecomputer
programusedforthestudyisonlyasgoodasthemodeluponwhichitisbased.FEMstudiesthatexaminedRME
werebasedupononedryhumanskulleach.Additionally,FEMstudiesdonotdemonstratelongitudinaleffects,
onlyaparticularinstantintime.
Manystudies5,8,1829haveattemptedtoquantifythechangesthatoccurinthemaxillarycomplexasaresultof
RME.Severalstudieshaveextensivelyreviewedthechangesoccurringatthemidpalatalsuture,thedentoalveolar
structures,andthenasalcavities.9,25,28,3033However,thelimitationsofclinicalexaminationsandtwo
dimensionalradiographyinhibittheanalysisofwhatisoccurringatthesuturallevelsinorthodonticpatients.The
introductionofconebeamcomputedtomography(CBCT)inOrthodontics34,35nowpermitstheexaminationofthe
craniofacialcomplexinliving,growingsubjects.
Thepurposeofthisstudyistousethreedimensionalimagestoevaluatethechangesthatoccuratthe
circummaxillarysutures,includingthefrontonasal,zygomaticomaxillary,intermaxillary,midpalatal,and
transpalatalones,followingrapidmaxillaryexpansioningrowingchildren.Inaddition,therelationshipbetween
themidpalatalsutureandtheothersuturesarealsoanalyzed.
MATERIALANDMETHODS

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Patientselection

ThisinvestigationisaretrospectivestudyapprovedbytheSaintLouisUniversityInstitutionalReviewBoard
(#15727).Therecordsof25consecutivelytreatedpatients(10male,15female)werechosenfromtherecordsof
privatepracticebasedonthefollowingselectioncriteria:
Inclusioncriteria

1.Diagnosisincludedafindingofskeletaltransversediscrepancy,whiletreatmentplanincludedtheuseofarapid
maxillaryexpansionappliance.
2.CompletesetofCBCTimagesincludingonepriortoappliancedeliveryandonetakenimmediatelyafterthe
activeexpansionphaseoftreatment.
Exclusioncriteria

1.Patientswithcraniofacialanomalies,includingcleftlipandpalate.
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2.Patientswithorthodonticappliancespresentpriortothestartoftreatmentwithrapidmaxillaryexpansion.
Patients'meanageatthetimeofthefirstimagingappointmentinthisstudywas12.32.6(8.3to17.8years).The
secondCBCTimagewastakenonanaverageof22.85daysafterthefirstimage(14to37days).
Eachpatientwastreatedwithatoothbornerapidmaxillaryexpander(Hyrax).Theexpansionapplianceconsisted
ofa7millimeterDentaurumexpansionscrew(Dentaurum,Ispringen,Germany)with0.051inchdiameterstainless
steelarmsweldedtoorthodonticbandsonthemaxillaryfirstmolars,anda0.051inchdiametersupportingwire
placedpalataltothedentitionandbandssoastoincreasetherigidityoftheapplianceandextendtheforceofthe
expandertothecaninesaswellasfirstandsecondpremolars,iftheywerepresent(Fig3).
Figure3
Modelofpalatalexpander.

Figure1
Frontalskullshowingevaluatedareas.

Figure2
Axialviewofaskullshowingevaluatedareas.A)MidpalatalsutureB)
TranspalatalsutureC)PNS.

Theexpanderwasactivatedtwoquarterturnsoftheexpansionscrew(0.2mmeachturn)atthetimeofdelivery,
followedbyaonequarterturntwiceaday.Activationofthescrewcontinueduntilthetransversediscrepancywas
overcorrectedtothepointinwhichthepalatalcuspsofthemaxillarymolarswereinedgetoedgecontactwiththe
buccalcuspsoftheopposingmandibularteeth.
Imaging

ConebeamcomputedtomographyscansweretakenusingtheClassiciCAT(ImagingSciencesInternational,
Inc.,Hatfield,USA)conebeamCTscanner.Allscansweretakenbythesametechnicianusingeitherthe16x13
orthe16x22centimeterfieldofviewwithavoxelsizeof0.4millimeters.Patientswerepositionedinavertical
seatwiththeirheadstabilizedintheheadresttopreventanyunwantedmovementduringthe20secondscan,teeth
togetherincentricocclusion,andtheFrankfortHorizontalplaneparalleltothefloor,asdeterminedbytheexternal
auditorymeatusandsofttissueorbitale.
Eachpatientwasscannedattwodifferenttimepoints:T0andT1.Thefirstimage(T0)wasobtainedpriortothe
deliveryoftheexpanderandrepresentedthesubject'sbaselineconditionpriortoexpansion.Thesecondtimepoint
(T1)wastakenattheappointmentimmediatelyfollowingthelastactivationoftheexpansionappliance.
Theanalysismeasuredchangesofthealveolarboneandmaxillarysuturesfollowingrapidmaxillaryexpansion
withconsistentlandmarkidentificationusingtheDolphin3Dsoftware(DolphinImaging&Management
Solutions,Chatsworth,USA).
Eachscanhadanumberrandomlyassignedandloadedintothethreedimensionalsoftwaresothateachscanwas
analyzedwithouttheoperatoridentifyingthepatient.First,eachscanwasorientedbylocatingthemidpoint
betweenbothforaminaspinosum(ELSA),andassigningtoitx=0,y=0,andz=0coordinates(Fig4).The
followingpointswerethenlocated:1)thesuperiorlateralborderoftheexternalauditorymeatus(SLEAM)onboth
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rightandleftsides,and2)themiddorsumoftheforamenmagnum(MDFM).Anaxialhorizontalplane(xyplane)
wasdeterminedbyusingtherightandleftSLEAMpointsandELSA.Asagittalverticalplane(zyplane)was
determinedperpendiculartothexyplaneandpassingthroughpointsELSAandMDFM.Thesepointshave
shownahighintrareliabilitywhenlocatedwith3Dimages,whichmakesthexyandzyplanesformedbythese
pointsanadequatewaytostandardizetheorientationof3Dimages.
Figure4
CBCTimageafterorientation.

Landmarklocation

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Twodimensionalaxialimageswerecreatedperpendiculartothecoronalplaneandusedtomeasuretheamountof
midpalatalandtranspalatalsutureseparationontheexternalsurfaceofeachsuture.
Themidpalatalsuturewasmeasuredadjacenttofourlocations:thefirstmolar,thecontactareabetweenthefirstand
secondpremolars,thecanine,andthemostanteriorpointofthemaxillarydentalarch.
Thecentralgrooveofeachfirstmolarwasidentifiedbylocatingthecrownofthemolaronanaxialimageand
markingthecentralgroove.Anaxialsectionthroughthehardpalatewasthencreated,andthemesialedgeofthe
midpalatalsuturewasmarkedonbothrightandleftsides.Thesameprocedurewasfollowedfortheotherareasof
themidpalatalsuture,asdescribedabove(Fig5).Toverifyiftheexternalsurfaceofthesuturewasbeingmarked,
coronalsliceswereviewedfortheplaceswherethesutureedgesweremarkedandcorrectedifnecessary.
Figure5
Axialslicethroughthepalateshowingthemidpalatalsuture.

Thetranspalatalsuturewasmeasuredatfiveareasalongthesuture.Thefirstareaidentifiedwasinthemidline,
establishedbythejunctionofthemidpalatalandtranspalatalsutures.Theproximalanddistaledgesofthe
transpalatalsutureweremarkedatthemidline,aswellasat6,12,and18millimeterstotheleft(Fig6).The
millimetricgridontheaxialimagewasusedtodeterminethelandmarkstotheleftofthemidline.Toverifyifthe
externalsurfaceofthesuturewasbeingmarked,coronalsliceswereviewedfortheplaceswherethesutureedges
weremarkedandcorrectedifnecessary.
Figure6
Axialslicethroughthepalateshowingthetranspalatalsuture.

Thedisplacementofthefrontonasalsuturewasdeterminedbylocatingandmarkingthesuperiorandinferioredges
ofthefrontonasalsutureontheexternalsurfaceinthemidlineonasagittalsection(Fig7).
Figure7
Sagittalslicethroughthemidline,withthefrontonasalsuturemarked.

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Axialsectionswereusedintheappropriatelocationstolocateandmeasurethemesialedgesoftheintermaxillary
sutureatANS(Fig8)aswellastheproximalanddistaledgesofthezygomaticomaxillarysutureswhichwere
locatedandmarkedonbothinferior(Fig9)andsuperior(Fig10)bordersofthezygomaticomaxillarysutureon
bothrightandleftsides.
Figure8
Axialslicethroughthehardpalate,withtheintermaxillarysuturemarkedat
ANSontherightandleftsides.

Figure9
Axialsliceshowingtheleftinferiorborderzygomaticomaxillarysuture.

Figure10
Axialsliceshowingtheleftsuperiorborderofzygomaticomaxillarysuture.

Todeterminetheamountofapplianceexpansion,theouteredgesofanunactivated7mmDentaurumexpansion
screw(Dentaurum,Ispringen,Germany)weremeasuredwithdigitalcalipers.Inthepostexpansionscans,theouter
edgesoftheexpansionscrewweremarkedinthecoronalsliceatthemaxillaryfirstmolars(Fig11).
Figure11
Postexpansioncoronalsliceatthecentralgrooveofthemaxillaryfirst
molar,withtheexpansionscrewinthecenter.
TheApointandtheposteriornasalspine(PNS)wereidentifiedonasagittalsection(Fig12).
Figure12
Apoint(right)andPNS(left)onasagittalslicethroughthemidline.

Toestablishtheamountofmaxillaryfirstmolarangulation,thelongaxisofeachfirstmolarwasdeterminedby
identifyingthecenterofthepulpchamberonaxialslicesatseverallevels.Then,theangleoftheeachmolarwas
calculatedtotheocclusalplane(Fig13).
Figure13
Angulationofthemaxillaryfirstmolarsmeasuredattheocclusalplane.

Foreachlandmarkdescribedabove,thex,y,andzcoordinateswererecordedatbothT0andT1foreachpatient.
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ThevalueinmillimetersforeachcoordinatewasenteredintoanExcelsoftwarespreadsheet(Microsoft,Redmond,
Washington,USA).Tocalculatethewidthofeachsuture,thedistancebetweenthetwoedgeswascalculatedfor
eachcoordinate.Tocalculatetheamountofexpansion,thedifferencebetweentherightandleftsidesofthe
expansionjackscrewwascomputedforeachcoordinate.Analyticalgeometrywasusedtoconverteachsetof
coordinatesintoasinglevalue.Theresultingvaluewasthewidthofasutureataparticularlocationortheamount
ofapplianceexpansion.Thesecalculationsweredoneforallofthex,y,andzcoordinatesforbothtimeintervals.
Statistics

AllstatisticswerecalculatedusingtheSPSS14.0StatisticalSoftware(SPSSInc.,Chicago,Illinois,USA)ona
personalcomputer.Descriptivestatisticswerecalculatedforallsuturewidthmeasurementsandforappliance
expansionaswellasmaxillaryfirstmolarangulationandchangeinpositionofApointandPNS.
Tocalculateintraexaminerreliability,25%oftheCBCTscanswereremeasuredtotestthereliabilityoflandmark
identificationwithanintraclasscorrelationcoefficient.Reliabilityofscanorientationwasalsocalculatedusingthe
intraclasscorrelationcoefficientbyreorienting25%oftheCBCTscansandusingthecranialbaselandmarks
basionandanteriorclinoidprocessofsellaturcicaforcomparison.
Nonparametricstatisticswereusedduetothesmallsamplesize.37Changesinmeasurementsbetweenpreandpost
expansionforeachofthesutureswereanalyzedusingsingletailedWilcoxonsignedranktestswithalevelof
significancesetatP<0.05.Kendall'sTaubcorrelationswithasignificancelevelsetatP<0.05werecalculatedto
assesstherelationshipsbetweenthevarioussuturesandtheamountofexpansion.
RESULTS

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Theintraclasscorrelationcoefficientprovedthemeasurementsandorientationtobeveryreliable.Cronbach's
Alphameasurementof0.947showedthattherewasnosignificantdifferencebetweentheoriginalmeasurements
madeandtherepeatedmeasurementsperformedonasamplethatwasrandomlyselectedandrepresentedin25%of
thesample.Likewise,Cronbach'sAlphameasurementof0.967showedthattherewasnosignificantdifference
betweentheoriginalorientationmadeandtherepeatedorientationperformedonasamplethatwasrandomly
selectedandrepresentedin25%ofthesample.
DescriptivestatisticsforthechangesinsuturewidthmeasurementsbetweenT0andT1aswellastheamountof
applianceexpansionarelistedinTable1.
Table1
Descriptivestatisticsofsuturaldisplacement(T1T0).

Statisticallysignificantdifferenceswerefoundforthesuturaldisplacementofthefrontonasalsuture(z=3.714,P<
0.001),therightsuperiorzygomaticomaxillarysuture(z=3.951,P<0.001),therightinferiorzygomaticomaxillary
suture(z=2.677,P<0.007),theleftsuperiorzygomaticomaxillarysuture(z=3.415,P<0.001),theleftinferior
zygomaticomaxillarysuture(z=3.633,P<0.001),theintermaxillarysuture,asmeasuredatANS(z=4.200,P<
0.001),andalllandmarksalongthemidpalatalsuture(P<0.001).Therewasnostatisticallysignificant
displacementregardingthetranspalatalsutureatanyofthemeasuredlandmarks.Apointhadastatistically
significantmovementafterRME,however,PNSdidnot,eventhoughithad1.03millimetersofmovement
downward.
Whentheindividualx,y,andzcoordinateswereevaluated,themovementoftheedgesofthesutureswasfoundto
besignificantinsomedirections.TheresultsarelistedinTable2.Figures14to18demonstratethesignificant
movementsforeachassessedsuture.Figure19demonstratesthemovementofApointandPNS.
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Table2
Significantmovementofindividualcoordinates.

Figure14
FrontonasalsuturemovementsinYandZplanes(sagittalslice).

Figure18
MidpalatalsuturemovementsinXandZplanes(axialslice).

Figure19
MovementsinYandZplanes(sagittalslice)ofApoint(right)andPNS
(left).
Figure15
IntermaxillarysuturemovementatANSinXplane(axialslice).

Figure16
SuperiorzygomaticomaxillarysuturemovementsinA)XandYplanes
(coronalslice)andB)XandZplanes(axialslice).
Figure17
InferiorzygomaticomaxillarysuturemovementsinXandZplanes(axial
slice).
Kendall'scorrelationsshowedweakrelationshipsbetweenthemidpalatalsutureatthefirstmolarandthe
frontonasalsuture(t=0.261,P<0.036)aswellasthesuperiorborderofthezygomaticomaxillarysutureandthe
midpalatalsutureat:themostanterioraspectofthedentalarch(t=0.418,P<0.002),thecontactbetweenfirstand
secondpremolars(t=0.322,P<0.012),andatthefirstmolar(t=0.364,P<0.006).Therewasalsoaweak
relationshipbetweentheinferiorborderofthezygomaticomaxillarysutureandthemidpalatalsutureatthemost
anterioraspectofthedentalarch(t=0.261,P<0.034).
Thedifferenceinangulationofthemaxillaryfirstmolarstotheocclusalplanewasstatisticallysignificant(right:z=
3.135,P<0.001,left:z=3.586,P<0.001)beforeandafterRME.PriortoRME,therightfirstmolarhadan
averageangulationof87.3whiletheleftfirstmolarhadanaverageangulationof84.4.AfterRME,therightfirst
molarscrowntippedbuccallywithanaverageresultingangleof82.3andtheleftfirstmolarscrownalsotipped
buccallywithanaverageresultingangleof78.8.Usinggeometrytocalculatetheintramolarangle,thepreRME
anglebetweenrightandleftmaxillaryfirstmolarswas12.3andafterRMEitincreasedto22.7.
DISCUSSION

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Todate,thereareanumberofmethodsforstudyingtheeffectsofrapidmaxillaryexpansion.However,the
literaturedoesnotreachaconsensusregardingwhichapproachissuperior.Inaddition,theuseofnondistorted
threedimensionalimagingisarelativelynewtechniquebeinginOrthodonticsusedtoquantifytheskeletaland
dentaleffectsofrapidmaxillaryexpansion.
Althoughtherearemanystudies5,8,1828regardingrapidmaxillaryexpansion,veryfewhaveusedconebeam
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computedtomographytechnology.25
Thesamplesizeof25wassubstantiallylargerthantheoneusedinmanyotherthreedimensionalstudies.Thisgave
morepowertothestatisticalanalysestorevealsignificantdifferenceswhentheyexisted.Thissamplewasalso
uniqueinthefactthattheCBCTimagesweretakenrelativelyclosetogether,withthesecondimageoccurring
shortlyaftertheactiveexpansionoftheappliancewasfinished.Thiseliminatesmostoftheremodelingandgrowth,
aswellasrelapsethatappearsinotherstudies.
ThemidpalatalsutureexhibitedsignificantdisplacementduetoRME,withtheamountofdisplacementbeing
greaterintheanteriorthanintheposterior.Asthisresultisconsistentwithpreviousstudies,5,8,1828the
displacementofothersutureswasofmoreinterestforthisstudy.Manystudieshaveconcludedthatthepalatal
shelvestipdownaswellasmoveaparttransverselyduringRME.Inthisstudy,onlythetransversemovementwas
showntobesignificantalongthemidpalatalsuturesedges.Therewassignificantdownwardmovementatthe
contactofthefirstandsecondpremolars,buttheamountwasonlyafractionofamillimeter.
Instudiescarriedoutwithrhesusmonkeys,Starnbach10notedthatduringRME,therewasincreasedcellular
activityatthezygomaticomaxillarysuture,indicatingboneformationatthatsuture.Incontrast,anotherstudy
conductedbyGardner13onadifferentgroupofrhesusmonkeysdidnotdemonstrateanyactivityatthatsuture
duringRME.FEMstudies15,16,17havesuggestedthatthezygomaticomaxillarysuturesareplacesofcompressive
forcesduringpalatalexpansion.Theresultsofthisstudyshowanaverageof1.2mmofsuturaldisplacementat
boththesuperiorandinferiorbordersofthesesutures,whichismoreconsistentwiththeresultsthatStarnbach10
showedhistologically.PreviousRMEstudiescarriedoutwithchildrendidnotassesszygomaticomaxillarysutures,
mostlikelyduetothedifficultyinidentifyingthesutureonposteroanteriororlateralcephalograms.Whenthe
individualplanesareevaluated,thesuperiorbordersofthezygomaticomaxillarysuturemovetransverselybyan
averageof1.54mm,butthebordersmoveslightlydownward(0.1mm)andforward(0.88mm)aswell.The
inferiorbordersoftheofthezygomaticomaxillarysuturealsomovetransverselybyanaverageof1.32mm,and
forwardbyanaverageof1.82mm.Thesefindingsareconsistentwiththeacceptedfactthattheentiremaxilla
movesdownandforwardwithRME.
Thefrontonasalsutureprovedtohaveasignificantamountofdisplacement,withanaveragedisplacementofonly
0.6mm.Themovementofthebordersofthissuturewasalsoinadownandforwarddirection,asexpected.
However,otherstudieshavesuggestedthatthegreatestresponsetomaxillaryexpansionoutsideoftheoralcavityis
foundatthissuture.12
Theintermaxillarysutureisusuallyincludedasanextensionofthemidpalatalsuture,sinceitappearstobe
continuouswiththatsuture.Thedisplacementoftheintermaxillarysuturewasmeasuredatitsmostapical
landmark,theANS.Itisinterestingtonotethatthisistheonlysuturewithsignificantdisplacementwhichhada
significantcorrelationwiththeamountofexpansionoftheappliance.Theonlysignificantmovementwasina
transversedirectionatANS.
AssessmentofApointshowedasignificantdisplacementbackward.Apointalsohadanaveragedisplacementof
nearly3mmdownward,butthiswasnotstatisticallysignificant.Additionally,PNShadanaveragedownward
displacementofabout1mm,whichwasnotstatisticallysignificant.Studieshaveshowncontradictoryresults
regardingthetippingofthepalatalplane,withsomestudiesshowingthattheposteriortippingwasgreaterthanthat
attheanterioraspect,whileotherstudiesshownosignificanttipping.Evenwithsomerelativelylargedownward
measurements,thisstudyprovedthatthetippingofthepalatalplaneisnotsignificantwithRME.
Thelackofsignificantchangeinthetranspalatalsutureappearstoconfirmapriorstudy7carriedoutwithdried
skullsandhumanpatientsinwhichthepalatinebonesdonotseparatefromthemaxillarybonesundertheforcesof
palatalexpansion.Timms7proposeditwastheconnectiontothesphenoidbonethatpreventedthesutural
displacementandthepterygoidprocessesfromsimplybendinginresponsetotheexpansionforces.Whilethe
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separationofthetranspalatalsuturewasnotstatisticallysignificant,therewassomeseparationinsomepatients.A
largersamplesizemaybeabletorefuteorconfirmtheseresults.
Onlytheexternalsurfacesofsutureswereexaminedduringthisstudy.ThechangesthatoccurredduringRME
wererecordedinallthreeplanesofspace.Theelementoftimewasdisregarded,sincetherewas,onaverage,only
about3weeksbetweenT0andT1.Whilethesubjectswereallgrowingchildren,theamountofgrowththatoccurs
over3weeksisnegligible.
TheRMEapplianceforthisstudywasdirectlyattachedtothemaxillaryfirstmolars,andonewouldexpectthatthe
molarswouldtipbuccallyasaresultoftheexpansionforces.Whiletherewereindividualvariations,themolarsdid
aspredictedwithabouta10degreeincreaseintheintermolarangleasaresultofRME.
ThisstudyhasestablishedthefactthatcircummaxillarysuturesareaffectedbyRMEingrowingchildren,andthat
themovementsoffacialbonescanbereliablyquantifiedinthreeplanesofspaceusingCBCT.Theoverallforward
anddownwardmovementofthemaxillacanbeseen,aswellasthetransversechanges.Individualassessmentof
thechangesoccurringatthemaxillarymolarscanalsobeperformed.Theresultsofthisstudyprovidealinkamong
thepriorstudiescarriedoutwithnonhumanprimates,dryskullsandcomputermodels,anddescribewhatactually
occursinthesuturesinpatients,astheresultofRMEtreatment.
CONCLUSIONS

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Rapidmaxillaryexpansionresultsinsignificantdisplacementofthefrontonasal,intermaxillary,
zygomaticomaxillaryandmidpalatalsuturesingrowingchildreninallthreeplanesofspace.
Footnotes

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Theauthorsreportnocommercial,proprietaryorfinancialinterestintheproductsorcompaniesdescribedinthisarticle.
Patientsdisplayedinthisarticlepreviouslyapprovedtheuseoftheirfacialandintraoralphotographs.
Howtocitethisarticle:WollerJL,KimKB,BehrentsRG,BuschangPH.Anassessmentofthemaxillaafterrapidmaxillary
expansionusingconebeamcomputedtomographyingrowingchildren.DentalPressJOrthod.2014JanFeb19(1):2635.doi:
http://dx.doi.org/10.1590/21769451.19.1.026035.oar

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