skeletal maturation of each subject.

A. Baldini*, A. Nota*, C. Santariello**,

Results The Wilcoxon rank-sum test shows
S. Caruso***, V. Assi****, F. Ballanti**,
statistically significant differences between the two
R. Gatto***, P. Cozza**
RME activation protocols only for overjet. Statistically
significant differences were reported in comparison
*Dental School, Vita-Salute San Raffaele University, Milan, Italy
with the control group.
**Department of Clinical Sciences and Translational Medicine,
Conclusions This study suggests that the increase
University of Rome Tor Vergata, Italy
in overjet after RME could be associated with faster
***Department MeSVA, University of L’Aquila, Italy
activation protocols especially in subjects with lower
****Edinburgh Clinical Trials Unit (ECTU), University of
skeletal maturation.
Edinburgh, United Kingdom

email: [email protected]
Keywords Cephalometry, Maxillary expansion,
DOI: 10.23804/ejpd.2018.19.02.10 Orthodontic appliances, Orthodontics, Palatal expansion.

Introduction
Sagittal dentoskeletal
Rapid maxillary expansion (RME) is the most effective
modifications common orthodontic treatment to correct a transverse
deficiency by opening the mid-palatal suture [Cross et
associated al., 2000; Haas, 1961; Lagravere et al., 2005; Lione et
al., 2013]. This allows an increase in maxillary width,
with different correction of posterior crossbites and the subsequent
maxillary and mandibular arch coordination, thus
activation protocols reducing the need for extractions [Baccetti et al., 2001;
Giuca et al., 2009; Grassia, D’Apuzzo, Ferrulli, et al.,
of rapid maxillary 2014; Needleman et al., 2000; Perillo et al., 2014].
RME generates large forces to exceed the limits of
expansion orthodontic tooth movement with the aim to achieve
minimal dental and maximum orthopaedic effect [Haas,
1961]. Anyway, it affects the circummaxillary suture
system and more specifically the mid-palatal suture,
but also compresses the periodontal ligament, bends
abstract the alveolar processes and induces a tipping of the
anchoring teeth and other skeletal and dental effects
Aim The aim of this study is to compare the sagittal as confirmed by numerous studies [Ballanti et al., 2009;
dentoskeletal changes associated with different Cameron et al., 2002; Haas, 1970; Rosa et al., 2016].
activation protocols of maxillary expander. In particular, the separation of the two palatine bones
Materials and methods A total of 101 subjects with along the palatal suture median is reflected on the nose-
constricted maxillary arches (49 males and 52 females; jaw complex in an area of triangular shape, the base of
mean age 10.08 ± 1.57 years) were enrolled in the study. which is located in correspondence of the anterior nasal
The study comprised also a control group of 20 subjects spine and the apex at the posterior nasal spine [Ballanti
(11 females and 9 males, mean age 10.27 ± 1.24 years) et al., 2016; Braun et al., 2000; Fastuca et al., 2015;
who were not treated during the observation period. Santariello et al., 2014].
All the subjects underwent rapid maxillary expansion Consequently, although RME has been recognised
with a stainless steel banded expander cemented to as a safe and reliable orthodontic procedure, some
the maxillary first molars. The expansion screw was investigations and literature reviews [Basciftci et al.,
randomly activated with two different rapid maxillary 2002; Lione et al., 2013; Rossi et al., 2011], have
expansion protocols (one-quarter per day or two- focused on the unwanted consequences of heavy forces
quarters per day). A statistical comparison between the on dento-skeletal structures and reported that RME
sagittal cephalometric variations obtained in the two with conventional appliances promotes the inferior
expansion groups was made, and compared with the displacement of the maxilla with a consequent posterior-
untreated control group. Data were then stratified for inferior rotation of the mandible [Lione et al., 2013].
Different frequency of the activations, magnitude of

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baldini a. et aL.

FIg. 1 Cephalometric parameters measured and analyzed.

the applied force, duration of the treatment, and patient the two activation protocols.
age produce different kind of expansions as rapid, semi- The aim of this study is to compare the sagittal dento-
rapid or slow maxillary expansion [Ramoglu et al., 2010] skeletal changes associated with different activation
with different dental and skeletal effects. The expansion protocols of maxillary expander.
force depends on the activation protocol; the screw is
commonly activated once or twice daily for about 2–4
weeks and a single activation produces approximately Materials and methods
3 to 10 pounds of force [Zimring et al., 1965]. Some
authors [Geran et al., 2006; Işeri et al., 2004; Sari et A total of 101 subjects with constricted maxillary
al., 2003] used a regimen of one-quarter turn per day arches (49 males and 52 females; mean age 10.08 ±
(1QD) in young patients reporting success with this 1.57 years) were enrolled in the study after signing an
protocol and stating that this regimen is not different informed consent form. Individual skeletal maturity
from the classic regimen of two-quarters turn per day was determined for each subject with the cervical
(2QD), suggesting the evaluation of slower rhythms of vertebral maturation (CVM) method assessed on lateral
RME in the mixed dentition. Thus Iseri and Ozsoy [Işeri et cephalograms [Baccetti et al., 2001, 2002]. Exclusion
al., 2004] called semi-rapid maxillary expansion (SRME) criteria included age older than 15 years; CVM more
an activation protocol that consisted in a two-quarters advanced than cervical stage (CS) 4 (postpubertal)
turn per day for the first week followed by one-quarter and the presence of previous periodontal disease,
turn per day for the next days, immediately after the neurological disease, and/or genetic disease. All the
separation of the intermaxillary suture by RME, in order subjects underwent RME with a stainless steel banded
to produce less tissue resistance. Recently some authors expander cemented to the maxillary first molars and
[Grassia, D’Apuzzo, DiStasio et al., 2014; Grassia, were randomly assigned to one of two groups according
D’Apuzzo, Ferrulli et al., 2014; Perillo et al., 2014] studied to the expansion protocol to be applied. In Group 1 (28
the effects of mixed maxillary expansion (MME), which females and 28 males, mean age 10.13 ± 1.46 years) the
is able to separate the two maxillary halves by multiple expansion screw was activated at 1QD (one activation,
activations at the first appointment, and continues with 0.2 mm per day), in Group 2 (24 females and 21 males,
a slow maxillary expansion (SME) protocol of one turn mean age 10.01 ± 1.71 years) the expansion screw was
every three days. activated at 2QD (two activations, 0.4 mm per day). In
To the authors’ knowledge only two studies [Perillo both groups, the expansion screw has been activated
et al., 2014; Ramoglu et al., 2010] compared the dento- until the molar overcorrection was reached; a clinical
skeletal effects obtained in patients treated with RME condition that is verified when the palatal cusps of
and other expansion procedures and only Ramoglu et upper first molars are in contact with vestibular cusps
al. [2010] analysed the sagittal dento-skeletal effects. of lower first molar. In the present study a control group
There are no studies that evaluate the influence of of 20 subjects (11 females and 9 males, mean age
the RME activation protocol on the associated dento- 10.27 ± 1.24 years) was involved who were not treated
skeletal effects. Recently, studies by Baldini et al. [2015, during the observation period. Lateral cephalometric
2017] showed that subjects who underwent RME with radiographs were taken by a single trained radiographer
a 1QD activation protocol reported significantly lower following a standardised protocol, before (T0) and
pain sensation compared with 2QD and that there are after the removal of the device, 6 months (T1) from
significant differences in dental arches changes between the end of the active phase. In the control group lateral

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 Developing dentition and occlusion in paediatric dentistry

cephalometric radiographs were taken after 7 months. and without adjusting the increases by the number of
The same operator manually traced each cephalogram, activations, in order to appreciate the differences of the
and a second operator checked landmarks and anatomic two interventions independently from the expansion
contours. In case of disagreement the cephalograms amount. Such adjustment was done dividing the
were retraced reaching a mutual satisfaction of both measures by the number of activations. Since a graphical
operators. exploratory analysis of the distribution of such changes
In order to assess the sagittal dento-skeletal changes suggested to reject normality, every comparison was
9 angular and 3 linear cephalometric parameters were evaluated using Wilcoxon rank-sum tests.
considered (Fig. 1): Secondary analyses included comparisons between
• SNA: maxillary position relative to cranial base; each intervention arm and the control group. The
• SNB: mandibular position relative to cranial base; comparisons were then repeated stratifying by gender,
• ANB: skeletal class; cervical stage at baseline. It should be noted that only
• SN^PP: angle between cranial base and palatal plane; cervical stages 1 and 2 were included in this analysis
• MP^PP: angle between mandibular and palatal plane; because of the low number of patients at a higher
• SN^MP: angle between mandibular plane and cranial cervical stage (CS3).
base; The significance level was set at 0.05. All analyses
• IsiP^SN: angle between cranial base and upper were performed with SAS software 9.4.
central incisor;
• IiiP^MP: angle between mandibular plane and lower
central incisor; Results
• Inter inc: interincisive angle;
• Wits: distance AO-BO; Comparison between 1QD and 2QD
• OVJ: overjet; Table 1 shows the comparison of the sagittal
• OVB: overbite. skeletal changes obtained after RME between the two
activation protocols. Analysing the descriptive statistics,
Statistical analysis all the mean measurements changes between T0 and
The distributions of the cephalometric measures are T1 appear low in both groups. Furthermore, changes
summarised and compared as mean and standard between 1QD and 2QD are similar; in fact, the Wilcoxon
deviation according to the different groups. rank-sum test shows statistically significant differences
The primary interest of this study was to evaluate of the parameters changes between the two RME
the sagittal side effects of the two interventions, i.e. activation protocols only for the OVJ parameter (p=0.04)
one or two daily RME activations, focusing on the that slightly decreases with the 1QD protocol and slightly
comparison of the final changes in measures (T1-T0) of increases with the 2QD. The mathematical adjustment
the two active groups. This was performed both with considering the number of activations of each subject

1QD 2QD P-VALUE CONTROL TABLE 1 Comparison of

T1-T0 T1-T0 T1-T0 parameters increases T1-T0
MEAN SD MEAN SD MEAN SD
(mm) between the two
groups and with the control
SNA (°) 1,05** 2,06 0,62 2,48 n.s. -0,34 1,17 group
SNB (°) 0,87* 1,53 0,68 2,32 n.s. 0,08 1,22
ANB (°) 0,19 1,44 0,24 1,59 n.s. -0,43 0,71
SN^PP (°) -0,64 4,42 -0,02 2,38 n.s. 0,40 1,80
MP^PP (°) -0,90 2,92 -0,31 2,73 n.s. -1,35 1,99
SN^MP (°) -0,46 2,97 -1,52 9,24 n.s. -0,91 2,55
IsiP^SN (°) -1,64 5,04 -0,78 6,29 n.s. -0,12 3,54
IiiP^MP (°) -2,39* 11,56 -0,29 4,97 n.s. 0,74 2,33
WITS (mm) -0,31* 3,40 0,12 1,96 n.s. -0,65 1,05
INTER_INC (°) 3,40 6,56 2,50 5,16 n.s. 0,43 3,44
OVJ (mm) -0,39 1,50 0,23° 1,89 0,038 -0,36 1,65
OVB (mm) 0,68 1,63 1,06 1,61 n.s. 0,43 0,67
p-value 1QD vs Control *=<0.05 **<0.01 ***<0.001
p-value 2QD vs Control °=<0.05 °°<0.01 °°°<0.001

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baldini a. et aL.

confirm the absence of significant differences, the 1QD 2QD P-VALUE

p-value of the OVJ parameter change (p=0.052) is at T1-T0 T1-T0
the limit of the significance level (Table 2).
MEAN SD MEAN SD
A stratified statistical analysis for cervical stage that
compares results obtained on CS1 and CS2 subjects SNA (°) 0,05 0,11 0,02 0,12 n.s.
shows that the difference observed between the two SNB (°) 0,05 0,1 0,03 0,12 n.s.
protocols on the OVJ variation is an effect obtained on ANB (°) 0,01 0,08 0,01 0,07 n.s.
the CS1 subjects, where the 2QD protocol causes a mean
SN^PP (°) -0,03 0,22 0,01 0,12 n.s.
increase of 0.65mm, while the 1QD protocol causes a
mean decrease of 0.44mm (p=0.01). On the contrary, MP^PP (°) -0,9 2,92 -0,31 2,73 n.s.
on CS2 subjects both activation protocols cause an OVJ SN^MP (°) -0,05 0,17 -0,01 0,14 n.s.
decrease. This difference was also confirmed by the IsiP^SN (°) -0,09 0,28 -0,04 0,32 n.s.
mathematically adjusted analysis (p=0.027) resulting
IiiP^MP (°) -0,09 0,35 -0,02 0,22 n.s.
that 0.2 mm of screw activation determined a mean
0.026 mm overjet increase. The 2QD group reported WITS (mm) -0,03 0,16 0,01 0,09 n.s.
a significantly higher OVB increase of 2.14 mm in CS2 INTER_INC (°) 0,2 0,36 0,12 0,26 n.s.
subjects (p=0.013) even after mathematical adjusting by OVJ (mm) -0,02 0,09 0,01 0,08 n.s.
activation number (p=0.015).
OVB (mm) 0,04 0,09 0,05 0,07 n.s.

Comparison with the control group

Table 1 also shows the comparison of both activation TABLe 2 Comparison between the two groups of parameters
protocols with the untreated control group. increases T1-T0 (mm) adjusted by the number of activations.
The 1QD protocol caused a statistically significant
mean relative increase of SNA (1.39°) SNB (0.79°)
and WITS (0,34 mm) and a mean relative decrease of with this result – also found a significant increase in SNA
IIIP^MP (3.13°). Differently, the 2QD protocol caused after SRME and stable values after RME, but differently
only a statistically significant mean relative increase of they did not find variations of SNB and obtained a
the OVJ (0.59 mm). consequent increase of the ANB value. Furthermore,
previous studies [Akkaya et al., 1998; Basciftci et al.,
2002; Sari et al., 2003] reported an SNA increase at
Discussion the end of the RME treatment. Anyway, these changes
are probably clinically not significant (lower than 1.05°
RME generates large forces to exceed the limits of with 0.43° of difference between the two protocols)
orthodontic tooth movement with the aim to achieve and when the two groups changes were compared, no
minimal dental and maximum orthopaedic effect, statistically significant differences were observed.
causing widening and gradual opening the mid-palatal A statistical direct comparison between the 1QD and
suture [Haas, 1961; Perillo et al., 2014]. The expansion 2QD activation protocols confirmed the absence of
force depends on the activation protocol; the screw, for significant differences.
example, can be activated once or twice daily for about In the 1QD group a significant lingual tipping
2–4 weeks and a single activation produces approximately movement of the inferior incisors teeth was shown by
3 to 10 pounds of force [Zimring et al., 1965]. a significant reduction of the IiiP^MP angle that, on the
A literature review by Lione et al. [2013] focused on the contrary, resulted stable in the 2QD group. Ramoglu et
unwanted consequences of RME reporting a downward al. [2010] also showed a variation of this parameter in
movement of the maxilla and a consequent downward the SRME group and stable values in the RME group,
and backward movement of the mandible. but differently they observed an increase of IiiP^MP.
In the present study, 9 angular and 3 linear Previously Basciftci and Karaman [2002] found the
cephalometric parameters were considered in order to absence of modifications for IiiP^MP and IsiP^SN after
evaluate the influence of the activation protocol on the RME. Furthermore, in the present study, the upper
sagittal dento-skeletal changes determined by RME. incisors inclination and the interincisive angle were not
To analyse the possible posterior-anterior movement affected by RME with both the activation protocols. The
of mandible and maxilla SNA and SNB angles were direct comparison between the two groups showed no
considered. In comparison with untreated subjects, a significant differences.
statistically significant relative increase of 1.39° and 0.79° The results of the present study showed that the 1QD
were respectively recorded for SNA and SNB only in the protocol maintained stable values of overjet and overbite
1QD group indicating an anterior movement of both differently from the 2QD protocol that determined a
maxilla and mandible with consequent stable values of significant mean relative increase of the overjet of 0.65
ANB. Previously, Ramoglu et al. [2010] – in agreement mm compared with the control group. Furthermore, a

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 Developing dentition and occlusion in paediatric dentistry

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