Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2021; 21(supp1):e0019

https://doi.org/10.1590/pboci.2021.087
ISSN 1519-0501 / eISSN 1983-4632

ORIGINAL ARTICLE

Spontaneous Transversal Changes of Lower Arch Following

Palatal Skeletal Expansion

Francesca Cremonini1 , Elena Adversi2, Paolo Albertini1 , Giorgio Alfredo Spedicato3 , Mario
Palone1

1Department of Orthodontics, School of Dentistry, University of Ferrara, Ferrara, Italy.

2Private Practice, Pesaro, Italy.
3Department of Banking and Insurance, Catholic University of Milan, Milan, Italy.

Correspondence: Francesca Cremonini, Assistant Research Department of Orthodontics, School of Dentistry University of
Ferrara, Ferrara, 44121, Italy. E-mail: [email protected]

Academic Editor: Alessandro Leite Cavalcanti

Received: 29 January 2021 / Review: 02 March 2021 / Accepted: 15 March 2021

How to cite: Cremonini F, Adversi E, Albertini P, Spedicato GA, Palone M. Spontaneous transversal changes of lower
arch following palatal skeletal expansion. Pesqui Bras Odontopediatria Clín Integr. 2021; 21(supp1):e0019.
https://doi.org/10.1590/pboci.2021.087

ABSTRACT
Objective: To evaluate how the lower arch spontaneously change after upper rapid palatal expansion in a
group of patients with transversal skeletal deficit. Material and Methods: Twenty-four patients treated by
the same orthodontist with a rapid palatal expander (RPE) bounded on a deciduous molar have been
selected. The sample was divided into two groups: no treatment was provided for group one, while group
two was treated using a lip bumper or Schwarz appliance. For each patient, dental casts were collected
when the RPE was bounded (T0) and at the end of treatment, 9 months ± 3 months later (T1). Each
outcome was analyzed, providing descriptive statistics, main effects significance tests and post-hoc analyses
with the objective to evaluate the variations between pre-treatment (TO) and post-treatment (T1) of each of
them. Results: If the linear measurements are considered, a significant beneficial effect on both arches is
observed. However, the upper arch always shows a major increase of all values at T1 with respect to the
lower arch. Even though the post-hoc tables indicate that time differences are all statistically significant
across considered partitions, the lower arch's increase is more pronounced in group two, where patients
were treated in both arches. If the angular measurements are concerned, the increase of lingual crown
inclination was found in all patients, independently from the type of treatment in lower arch. Conclusion:
All patients show normalization of upper diameters, regardless of whether the lower arch was treated or
not.

Keywords: Orthodontics; Palatal Expansion Technique; Orthodontics, Corrective.

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Association of Support to Oral Health Research - APESB
 Pesqui. Bras. Odontopediatria Clín. Integr. 2021; 21(supp1):e0019

Introduction
Correction of transversal maxillary diameters is an important goal of orthodontic treatment: narrow
arches and posterior crossbite are constant findings in daily practice [1-3]. A rapid palatal expander (RPE) is
the most effective device at our disposal if the purpose is to obtain a widening of the median palatal suture and,
consequently, skeletal expansion of the upper arch [4,5]. Some cases of maxillary transverse contraction do
not show any posterior crossbite due to the establishment of lower premolars and molars compensations.
Because of reduced upper transversal diameters, posterior lower teeth tend to physiologically assume a
negative torque to compensate the skeletal palatal deficit [6]. To obtain a recovery of lower arch transversal
diameters and a decompensation of posterior teeth negative torque after expansion of upper arch, many devices
have been proposed [7-9].
One of the most used is a removable lip bumper, particularly useful in those patients where buccal and
labial muscles are quite contracted [10]. It is placed away from teeth and shield to the adjacent soft tissue
forces. It must be worn full time to obtain the desired results. It also increases the arch length through passive
lateral and anterior expansion, it’s also effective in straightening teeth and gaining posterior space by
distalizing the arch [11,12].
Murphy et al. [13] found that 50% of the mandibular expansion gained using lip-bumper is
concentrated in the first 100 days and that 90% is obtained in the first 300 days [14]. This points out how the
appliance is effective in decompensate the collapse of the lower arch after palatal expansion.
Alternatively, to expand the lower arch, a mandibular Schwarz appliance can be used. It fits along the
lingual edge of the mandibular dentition and it extends along the gum line. An expansion screw is incorporated
into the acrylic and should be activated once a week, with 0.25-0.50 of transversal vestibular crown tipping
[15]. It has been demonstrated significant long-term stability of maxillary and mandibular perimeter
augmentation (3.8-3.7 mm) using a Schwarz appliance and maxillary RPE [16-18].
Even if we don’t use any mandibular devices, Haas stated that after a palatal expansion of 12-14 mm, a
significant spontaneous expansion of the lower arch occurs due to an altered muscular balance between the
tongue and the buccinators [19]. According to previous study [10], a permanent increase in the maxillary
apical base leads to a significant and stable spontaneous increase in the mandibular arch's width.
Indeed, we intend to evaluate how the lower arch spontaneously changes after upper rapid palatal
expansion in a group of patients with a transversal skeletal deficit. The null hypothesis claims that an
untreated contracted lower arch allows the same upper expansion of a treated lower arch for its correct
decompensation.

Material and Methods

Study Design and Sample
In this prospective study, twenty-four patients with mixed dentition in a pre-pubertal phase have been
selected with the following inclusion criteria: 1) No previous orthodontic treatment; 2) ANB > 2°; 3) Cervical
vertebral maturation stage: CVS1, according to Baccetti et al. [20]; 4) Upper transverse skeletal deficit; and 5)
Compensatory contraction of the lower arch, with deep Wilson Curve. They have all been treated by the same
orthodontist with a rapid palatal expander (Dentaurum Hyrax 10, Leone s.p.a, Sesto Fiorentino, Italy), bonded
on deciduous second molar to minimize dental effects and any side effects on permanent teeth [21].

Clinical Procedures

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The activation of ¼ round/day was performed since the contact of palatal cusps of the first upper
molars with vestibular cusps of first lower molars (Figure 1).

Figure 1. The limit of transversal palatal expansion is given by the contact with the lower arch.

At the end of palatal expansion, the total sample was divided into two groups, depending on the type
of treatment chosen for lower arch:
• Group 1 (11 patients - 4 males and 7 females - 8 years and 6 months): spontaneous expansion of lower
arch, with no appliances used;
• Group 2 (13 patients - 3 males and 10 females - 9 years and 4 months): a mandibular appliance was used
to obtain a transversal expansion. Seven of these patients were treated with lip bumper, activated every
month, and six with Schwarz appliance activated with ¼ round/week.
Since it is not possible to structure such a double-blind study, the patients were divided into the two
study groups based on when they arrived at our observation: the first patient was assigned to group one, and
so on alternately. For each one, dental casts were collected when the RPE was bounded (T0) and at the end of
treatment, 9 months ± 3 months later (T1). Then, all dental casts were scanned using an extraoral scanner
(Optical ReVeng Orthodontic, Open Tech 3d srl, Italy). Virtual tridimensional scans (file.stl) were imported in
NemoCast 3D (Nemotec Dental System, Dentaurum Italia s.p.a, Bentivoglio, Italy) to make the following
measurements: inter canine, inter molar, inter bicuspid diameters and the first permanent molar inclination in
both arches. All measurements were made by the same operator, who was kept blind. Moreover, arch width
was calculated from the lingual side of each tooth, considering the gingival margin at the lingual sulcus of the
first permanent molar, as described by Brust and McNamara [22] (Figure 2). Finally, the numbers of appliance
activations were registered to compare different protocols.

Figure 2. Reference points for width arch calculation.

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Statistical Analysis
A 13-rows dataset was collected on which the following outcomes were recorded: A) Inter canine
distance; B) Inter first bicuspid distance; C) Inter second bicuspid distance; D) Inter molar distance; E) Torque
right size; and F) Torque left size.
To simplify the analysis and interpretation of the results, each of the six variables was recalculated as
the difference between T1 and T0: positive values indicate an increase in distances/degrees at T1. When close
to zero, it points out stability between pre- and post-treatment. The study aims to statistically assess any
differences between the two groups among times.
About the distances, descriptive statistics (number, average, and standard deviation) were carried out
for each variable “distance” split by time, arch and group. It was verified whether the time, arch and group
distances were different from each variable “distance” using a linear mixed model [23] and post-hoc tests on
marginal means [24] using the Tukey approach. The linear mixed models included arch, group and time
(when available) main effects and interaction, patient as a random effect (to allow for repeated measures).
Normality test on the models’ residuals results was tested with the Shapiro-Wilk test. The statistical software
R [25] and associated packages were used for statistical modeling. Statistical significance was assessed using a
threshold of α=0.05 (5%).

Results
According to the non-parametric Mann-Whitney test, the second group of patients, treated using lip
bumper or Schwarz appliance, can be considered as one because none of the variables show any statistical
significant difference.
If the linear measurements are considered, a significant beneficial effect on both arches is observed.
However, the upper arch always shows a major increase of all values at T1 concerning the mandibular arch
(Tables 1 to 4). Even though an increase in all diameters was confirmed, the increase in lower arch is more
pronounced in group two, where patients were treated in both arches (Figure 3).

Table 1. Inter canine distance: mean (SD) of the difference T1-T0.

Time Arch Group N Mean SD
T1 Upper Upper + Lower 13 26.0 3.77
T1 Upper Upper Only 11 26.3 4.46
T1 Lower Upper + Lower 13 21.7 3.11
T1 Lower Upper Only 11 22.7 3.07
T2 Upper Upper + Lower 13 29.8 4.03
T2 Upper Upper Only 11 30.4 4.10
T2 Lower Upper + Lower 13 24.3 3.14
T2 Lower Upper Only 11 23.7 3.27

Table 2. Inter first bicuspid distance: mean (SD) of the difference T1-T0.
Time Arch Group N Mean SD
T1 Upper Upper + Lower 13 28.1 4.29
T1 Upper Upper Only 11 28.7 4.55
T1 Lower Upper + Lower 13 25.8 3.23
T1 Lower Upper Only 11 27.0 3.18
T2 Upper Upper + Lower 13 33.0 4.52
T2 Upper Upper Only 11 33.6 4.53
T2 Lower Upper + Lower 13 28.2 2.89
T2 Lower Upper Only 11 27.8 3.24

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Table 3. Inter second bicuspid distance: mean (SD) of the difference T1-T0.
Time Arch Group N Mean SD
T1 Upper Upper + Lower 13 32.5 5.11
T1 Upper Upper Only 11 32.7 5.19
T1 Lower Upper + Lower 13 30.3 4.12
T1 Lower Upper Only 11 32.4 4.37
T2 Upper Upper + Lower 13 37.0 5.06
T2 Upper Upper Only 11 38.1 5.50
T2 Lower Upper + Lower 13 33.1 4.10
T2 Lower Upper Only 11 33.5 4.53

Table 4. Inter molar distance: mean (SD) of the difference T1-T0.

Time Arch Group N Mean SD
T1 Upper Upper + Lower 13 37.4 5.94
T1 Upper Upper Only 11 36.7 6.23
T1 Lower Upper + Lower 13 35.4 4.71
T1 Lower Upper Only 11 37.0 5.02
T2 Upper Upper + Lower 13 41.8 6.00
T2 Upper Upper Only 11 41.8 6.43
T2 Lower Upper + Lower 13 37.9 4.70
T2 Lower Upper Only 11 38.1 5.08

Figure 3. Trend over time of the parameter: (A) Inter canine diameter; (B) Inter first bicuspid diameter;
(C) Inter second bicuspid diameter; (D) Inter molar diameter.

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If the angular measurements of the lower arch are considered, the factor "arches" is the one that shows
a greater significance: on average, crown inclination values of mandibular arch increase more than the crown
inclination values of the upper arch (Table 5). The type of treatment does not determine any kind of variation
in results (Figure 4).

Table 5. Torque left and right side: mean (SD) of the difference T1-T0.
Time Arch Group N Left Side Right Side
Mean SD Mean SD
T1 Upper Upper + Lower 13 -15.06 6.86 -12.45 5.21
T1 Upper Upper Only 11 -13.97 6.09 -15.16 7.60
T1 Lower Upper + Lower 13 -46.33 6.56 -45.59 6.46
T1 Lower Upper Only 11 -43.23 7.98 -43.84 5.82
T2 Upper Upper + Lower 13 -6.98 4.42 -7.23 4.98
T2 Upper Upper Only 11 -7.81 3.16 -7.58 5.29
T2 Lower Upper + Lower 13 -34.61 5.75 -34.62 4.89
T2 Lower Upper Only 11 -35.50 4.61 -35.70 6.79

Figure 4. Trend over time of the parameter: (A) Torque left size; (B) Torque right size.

The post-hoc tables indicate that time differences are statistically significant across considered
partitions (Tables 6 to 11). Statistically significant differences between group 1 and group 2 were observed for
each outcome, except for inter molar distance and torque right/left inclination (Figures 5 to 10). The post-hoc
tables indicate that time differences are all statistically significant across considered partitions. The p-values of
the Shapiro-Test (p>0.05) indicate that the normality assumptions on which the modeling approach is based
hold for all variables (Table 12).

Table 6. Post-hoc analysis: Inter canine distance.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower 3.78 0.362 162 3.062 4.49 10.43 0.000
T1-T0 Lower Upper + Lower 2.60 0.362 162 1.885 3.31 7.18 0.000
T1-T0 Upper Upper Only 4.13 0.394 162 3.350 4.90 10.49 0.000
T1-T0 Lower Upper Only 1.06 0.394 162 0.284 1.84 2.70 0.008

Table 7. Post-hoc analysis: Inter first bicuspid distance.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower 4.911 0.368 162 4.184 5.64 13.34 0.000
T1-T0 Lower Upper + Lower 2.427 0.368 162 1.700 3.15 6.59 0.000
T1-T0 Upper Upper Only 4.867 0.400 162 4.077 5.66 12.16 0.000
T1-T0 Lower Upper Only 0.845 0.400 162 0.055 1.64 2.11 0.036

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Table 8. Post-hoc analysis: Inter second bicuspid distance.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower 4.46 0.409 162 3.650 5.26 10.91 0.000
T1-T0 Lower Upper + Lower 2.84 0.409 162 2.029 3.64 6.94 0.000
T1-T0 Upper Upper Only 5.35 0.444 162 4.475 6.23 12.05 0.000
T1-T0 Lower Upper Only 1.02 0.444 162 0.145 1.90 2.30 0.023

Table 9. Post-hoc analysis: Inter molar distance.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower 4.37 0.423 162 3.530 5.20 10.32 0.000
T1-T0 Lower Upper + Lower 2.46 0.423 162 1.629 3.30 5.83 0.000
T1-T0 Upper Upper Only 5.12 0.460 162 4.213 6.03 11.13 0.000
T1-T0 Lower Upper Only 1.13 0.460 162 0.223 2.04 2.46 0.015

Table 10. Post-hoc analysis: Torque left side.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower -8.09 1.66 67 -11.40 -4.77 -4.87 0.000
T1-T0 Lower Upper + Lower -11.72 1.66 67 -15.04 -8.41 -7.07 0.000
T1-T0 Upper Upper Only -6.16 1.80 67 -9.76 -2.56 -3.42 0.001
T1-T0 Lower Upper Only -7.73 1.80 67 -11.33 -4.13 -4.28 0.000

Table 11. Post-hoc analysis: Torque right side.

Contrast Arch Group Estimate SE Df Lower.CL Upper.CL T.ratio p-value
T1-T0 Upper Upper + Lower -5.21 2.00 67.1 -9.21 -1.22 -2.61 0.011
T1-T0 Lower Upper + Lower -10.97 2.00 67.1 -14.96 -6.98 -5.48 0.000
T1-T0 Upper Upper Only -7.58 2.17 67.1 -11.92 -3.24 -3.49 0.001
T1-T0 Lower Upper Only -8.14 2.17 67.1 -12.48 -3.80 -3.74 0.000

Table 12. Shapiro-Wilk test p-values on model’s residuals.

Variables p-value
Inter Canine Distance 0.437
Inter First Bicuspid Distance 0.701
Inter Second Bicuspid Distance 0.300
Inter Molar Distance 0.828
Torque Right Size 0.048
Torque Left Size 0.273

On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 5. Post hoc analysis for inter-canine diameter with confidence bands.

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On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 6. Post hoc analysis for inter first bicuspid diameter with confidence bands.

On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 7. Post hoc analysis for inter second bicuspid diameter with confidence bands.

On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 8. Post hoc analysis for inter molar diameter with confidence bands.

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On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 9. Post hoc analysis for torque left size with confidence bands.

On the abscissa, the estimated values of the marginal effects of the model, while on
the ordinate the time differences in relation to the arch and the group.

Figure 10. Post hoc analysis for torque right size with confidence bands.

Discussion
The objective of orthopedic treatment is to obtain an ideal skeletal relationship between the
maxillaries. Rapid maxillary expansion (RME) has always been the election treatment for the correction of
posterior crossbite and transverse deficiency, thanks to the possibility of separating the mid-palatal suture
before its ossification [16].
Although orthopedic treatment effects with RPE have been widely studied, little is known about
dentoalveolar effects of RME in mandibular arch [26]. The assumption has been that upper expansion could
induce functional uprighting of mandibular posterior teeth. However, some studies have confirmed [27], while
others have refuted [28], the spontaneous increase in lower inter molar and inter canine widths, no definitive
consensus was reached.

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Indeed, the maxillary skeletal morphology seems to influence the mandibular dentition position more
than the lower jaw's size and shape. Weak evidence suggests that using a lower appliance, such as a lip bumper,
can determine a further increase in mandibular arch perimeter after rapid upper expansion [29]. Another
conclusion was made by O'Grady et al. [16], who stated that Schwarz appliance's use leads to a major
expansion of mandibular arch in the long term. In the current study, although all patients show an increase of
lower diameters, the ones treated with lip bumper or Schwarz appliance gained a more statistically significant
expansion.
The graphical interpretation of the post hoc analysis highlights that all outcomes have a higher
estimated value at T1 concerning T0, which is statistically significant just in the lower arch for inter canine,
inter first and second bicuspid diameter. However, the difference in linear distances at T1 and T0 are positive
in both groups, indicating that in any case, an increase of mandibular widths is observed, independently from
the kind of lower treatment. This result is comparable to the conclusions made by Lima et al. [27], who
pointed out that the mandibular arch tends to fit the upper arch once expanded. They hypothesize that occlusal
forces and tongue/perioral muscles balance to play the most important role.
Handelman et al. [30] and McNamara et al. [31] found very similar improvements concerning the
maxillary molars and bicuspids (between 4.8 and 3.7 mm for molars and first bicuspids, and between 2.3 and
2.2 mm for second bicuspids). For the mandibular arch widths, much less expansion was found in the first
study. A possible explanation is that the sample of Handelman et al. [30] was made of adult patients, whereas
McNamara's sample was made of adolescents. Moussa et al. [32] also concluded that the lower inter molar and
inter cuspid widths in adult patients presented a greater relapse tendency because structures are less adaptable
in adult patients. However, in this study, the patients were examined at the end of the second phase of
treatment using a fixed appliance. Currently, we analyzed just short-term effects.
It is crucial that the upper expansion stops when the first upper molar palatal cusp encounters the first
lower molar vestibular cusp. This contact creates a slide surface, which allows a lower self-expansion through
masticatory forces and neuromuscular system [6]. Even the tongue pressure, maintained low by the presence
of RPE, could be a further stimulation to lower expansion. In the alternative, many different functional
appliances are available to remove possible external pressure to spontaneous expansion.
A great limit of the current study is the sample and variable sample considered. The number of
predictors and the model design (mixed effect models with interaction and control variables) do not permit to
use close-form analytical formulas to assess numerically the sample adequacy.
Future studies may have the goal of including an increased number of patients treated with the same
expansion protocol in both arches. Moreover, it would also be interesting to evaluate the long-term effects of
maxillary and mandibular skeletal expansion obtained at this age.
It must be pointed out that the present study tested just conventional palatal expander. Recently,
miniscrew supported expanders have been proposed, showing excellent mechanical properties with miniscrews
of different diameters and materials [33-35] and reducing the risk of root resorption [36].
Previous evidence confirmed that skeletal anchorage could increase the skeletal effect of RME,
extending the benefits of this therapy to late adolescence and adulthood. Also, it appeared that bone-borne
RME limited the tipping of posterior maxillary teeth. However, just one CBCT study has assessed the
potential effects of bone-borne RME on the mandibular arch compared to conventional tooth-borne RME.
From a clinical perspective, the conclusion was that the small amount of post-treatment expansion in the
mandible would not determine a significant gain of space in the lower arch after RME.

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Conclusion
All patients show normalization of upper diameters, regardless of whether the mandibular arch was
treated or not. However, it is pointed out that if the patients where mandibular arch was treated by means of
Lip bumper or Schwarz appliance, the lower dentoalveolar effects were pronounced. This means that the null
hypothesis cannot be accepted. The major lower expansion allowed after using lip bumper or Schwarz
appliance is statistically significant but not clinically relevant. This is confirmed by the fact that the mandibular
arch's decompensation was equally obtained in all patients.

Authors’ Contributions
FC https://orcid.org/0000-0002-4641-2196 Conceptualization, Methodology, Formal Analysis, Investigation, Writing - Original Draft and
Writing - Review and Editing.
EA --- Data Curation and Writing - Review and Editing.
PA https://orcid.org/0000-0002-4020-5065 Formal Analysis and Writing - Review and Editing.
GAS https://orcid.org/0000-0002-0315-8888 Formal Analysis.
MP https://orcid.org/0000-0001-6198-3053 Conceptualization and Writing - Review and Editing.
All authors declare that they contributed to critical review of intellectual content and approval of the final version to be published.

Financial Support
None.

Conflict of Interest
The authors declare no conflicts of interest.

Data Availability
The data used to support the findings of this study can be made available upon request to the corresponding author.

References
[1] Thilander B, Wahlund S, Lennartsson B. The effect of early interceptive treatment in children with posterior cross-
bite. Eur J Orthod 1984; 6(1):25-34. https://doi.org/10.1093/ejo/6.1.25.]
[2] Kurol J, Berglund L. Longitudinal study and cost-benefit analysis of the effect of early treatment of posterior cross-
bites in the primary dentition. Eur J Orthod 1992; 14(3):173-9. https://doi.org/10.1093/ejo/14.3.173
[3] Arreghini A, Lombardo L, Mollica F, Siciliani G. Torque expression capacity of 0.018 and 0.022 bracket slots by
changing archwire material and cross section. Prog Orthod 2014; 15(1):53.
https://doi.org/10.1186/s40510-014-0053-x
[4] Gracco A, Luca L, Cozzani M, Siciliani G. Assessment of palatal bone thickness in adults with cone beam
computerised tomography. Aust Orthod J 2007; 23(2):109-13.
[5] Zhou Y, Long H, Ye N, Xue J, Yang X, Liao L, et al. The effectiveness of non-surgical maxillary expansion: a meta-
analysis. Eur J Orthod 2014; 36(2):233-42. https://doi.org/10.1093/ejo/cjt044
[6] Mutinelli S, Manfredi M, Cozzani M. A mathematic-geometric model to calculate variation in mandibular arch form.
Eur J Orthod 2000; 22(2):113-25. https://doi.org/10.1093/ejo/22.2.113
[7] Haas AJ. Rapid expansion of the maxillary dental arch and nasal cavity by opening the midpalatal suture. Angle
Orthod 1961; 31(2):73-90.
[8] Pisani L, Bonaccorso L, Fastuca R, Spena R, Lombardo L, Caprioglio A. Systematic review for orthodontic and
orthopedic treatments for anterior open bite in the mixed dentition. Prog Orthod 2016; 17(1):28.
https://doi.org/10.1186/s40510-016-0142-0
[9] Lombardo L, Toni G, Stefanoni F, Mollica F, Guarneri MP, Siciliani G. The effect of temperature on the mechanical
behavior of nickel-titanium orthodontic initial archwires. Angle Orthod 2013; 83(2):298-305.
https://doi.org/10.2319/040612-287.1
[10] Greenfield RL. Clinical application of a modified lip bumper. J Clin Orthod 2011; 45(2):99-111.
[11] Buschang PH. Maxillomandibular expansion: short-term relapse potential and long-term stability. Am J Orthod
Dentofacial Orthop 2006; 129(4 Suppl):S75-S79. https://doi.org/10.1016/j.ajodo.2005.09.019
[12] Di Fazio D, Lombardo L, Gracco A, D'Amico P, Siciliani G. Lip pressure at rest and during function in 2 groups of
patients with different occlusions. Am J Orthod Dentofacial Orthop 2011; 139(1):e1-e6.
https://doi.org/10.1016/j.ajodo.2010.02.030

11
 Pesqui. Bras. Odontopediatria Clín. Integr. 2021; 21(supp1):e0019

[13] Murphy CC, Magness WB, English JD, Frazier-Bowers SA, Salas AM. A longitudinal study of incremental
expansion using a mandibular lip bumper. Angle Orthod 2003; 73(4):396-400.
[14] Arreghini A, Trigila S, Lombardo L, Siciliani G. Objective assessment of compliance with intra- and extraoral
removable appliances. Angle Orthod 2017; 87(1):88-95. https://doi.org/10.2319/020616-104.1
[15] Motoyoshi M, Hirabayashi M, Shimazaki T, Namura S. An experimental study on mandibular expansion: increases in
arch width and perimeter. Eur J Orthod 2002; 24(2):125-30. https://doi.org/10.1093/ejo/24.2.125
[16] O'Grady PW, McNamara JA Jr, Baccetti T, Franchi L. A long-term evaluation of the mandibular Schwarz appliance
and the acrylic splint expander in early mixed dentition patients. Am J Orthod Dentofacial Orthop 2006; 130(2):202-
13. https://doi.org/10.1016/j.ajodo.2004.12.023
[17] Lopez MA, Andreasi Bassi M, Confalone L, Gaudio RM, Lombardo L, Lauritano D. Retrospective study on bone-
level and soft-tissue-level cylindrical implants. J Biol Regul Homeost Agents 2016; 30(2 Suppl 1):43-8.
[18] Lopez MA, Andreasi Bassi M, Confalone L, Gaudio RM, Lombardo L, Lauritano D. Clinical outcome of 215
transmucosal implants with a conical connection: a retrospective study after 5-year follow-up. J Biol Regul Homeost
Agents 2016; 30(2 Suppl 1):55-60.
[19] Haas AJ. Long-term posttreatment evaluation of rapid palatal expansion. Angle Orthod 1980; 50(3):189-217.
[20] Baccetti T, Franchi L, McNamara Jr JA. The cervical vertebral maturation (CVM) method for the assessment of
optimal treatment timing in dentofacial orthopedics. Semin Orthod 2005; 11(3):119-29.
[21] Cozzani M, Rosa M, Cozzani P, Siciliani G. Deciduous dentition-anchored rapid maxillary expansion in crossbite and
non-crossbite mixed dentition patients: reaction of the permanent first molar. Prog Orthod 2003; 4:15-22.
https://doi.org/10.1034/j.1600-9975.2002.02034.x
[22] Brust EW, McNamara JA Jr. Arch Dimensional Changes Concurrent with Expansion in Mixed Dentition Patients.
In: Trotman CA, McNamara JA Jr, Editors. Orthodontic Treatment: Outcome and Effectiveness. Monograph 30.
Craniofacial Growth Series. Ann Arbor: Center for Human Growth and Development; University of Michigan; 1995.
[23] Bates D, Machler M, Bolker B, Walker S. Fitting linear mixed-effects Models using Ime4. J Stat Softw 2015; 67(1):1-
48.
[24] Ghasemi A, Zahediasl S. Normality tests for statistical analysis: A guide for Non-statisticans. Ann Stat 2001;
29(4):1165-88.
[25] R Core Team. 2020. R: A Language and Environment for Statistical Computing. Vienna, Austria: R Foundation for
Statistical Computing. Available from: https://www.R-project.org/. [Accessed on January 10, 2021].
[26] Küçükkeleş N, Ceylanoğlu C. Changes in lip, cheek, and tongue pressures after rapid maxillary expansion using a
diaphragm pressure transducer. Angle Orthod 2003; 73(6):662-8.
[27] Lima AC, Lima AL, Lima Filho RM, Oyen OJ. Spontaneous mandibular arch response after rapid palatal expansion: a
long-term study on Class I malocclusion. Am J Orthod Dentofacial Orthop 2004; 126(5):576-82.
[28] Petrén S, Bondemark L. Correction of unilateral posterior crossbite in the mixed dentition: a randomized controlled
trial. Am J Orthod Dentofacial Orthop 2008; 133(6):790.e7-13. https://doi.org/10.1016/j.ajodo.2007.11.021
[29] Santana LG, de Campos França E, Flores-Mir C, Abreu LG, Marques LS, Martins-Junior PA. Effects of lip bumper
therapy on the mandibular arch dimensions of children and adolescents: A systematic review. Am J Orthod
Dentofacial Orthop 2020; 157(4):454-465.e1. https://doi.org/10.1016/j.ajodo.2019.10.014
[30] Handelman CS, Wang L, BeGole EA, Haas AJ. Nonsurgical rapid maxillary expansion in adults: report on 47 cases
using the Haas expander. Angle Orthod 2000; 70(2):129-44.
[31] McNamara JA Jr, Baccetti T, Franchi L, Herberger TA. Rapid maxillary expansion followed by fixed appliances: a
long-term evaluation of changes in arch dimensions. Angle Orthod 2003; 73(4):344-53.
[32] Moussa R, O'Reilly MT, Close JM. Long-term stability of rapid palatal expander treatment and edgewise
mechanotherapy. Am J Orthod Dentofacial Orthop 1995; 108(5):478-88.
https://doi.org/10.1016/s0889-5406(95)70048-x
[33] Sfondrini MF, Gandini P, Alcozer R, Vallittu PK, Scribante A. Failure load and stress analysis of orthodontic
miniscrews with different transmucosal collar diameter. J Mech Behav Biomed Mater 2018; 87:132-7.
https://doi.org/10.1016/j.jmbbm.2018.07.032
[34] Krüsi M, Eliades T, Papageorgiou SN. Are there benefits from using bone-borne maxillary expansion instead of
tooth-borne maxillary expansion? A systematic review with meta-analysis. Prog Orthod 2019; 20(1):9.
https://doi.org/10.1186/s40510-019-0261-5
[35] Lo Giudice A, Ronsivalle V, Lagravere M, Leonardi R, Martina S, Isola G. Transverse dentoalveolar response of
mandibular arch after rapid maxillary expansion (RME) with tooth-borne and bone-borne appliances. Angle Orthod
2020; 90(5):680-7. https://doi.org/10.2319/042520-353.1
[36] Lombardo L, Carinci F, Martini M, Gemmati D, Nardone M, Siciliani G. Quantitive evaluation of dentin sialoprotein
(DSP) using microbeads - a potential early marker of root resorption. Oral Implantol 2016; 9(3):132-42.
https://doi.org/10.11138/orl/2016.9.3.132

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