biomedicines

Article
Skeletal and Dentoalveolar Changes in Growing Patients
Treated with Rapid Maxillary Expansion Measured in 3D
Cone-Beam Computed Tomography
Peri Colino-Gallardo 1 , Irene Del Fresno-Aguilar 1 , Laura Castillo-Montaño 1 , Carlos Colino-Paniagua 1 ,
Hugo Baptista-Sánchez 2 , Laura Criado-Pérez 2, * and Alfonso Alvarado-Lorenzo 2

1 Department of Dentistry, Universidad Católica San Antonio de Murcia, 30107 Murcia, Spain;
[email protected] (P.C.-G.); [email protected] (I.D.F.-A.);
[email protected] (L.C.-M.); [email protected] (C.C.-P.)
2 Department of Oral Surgery, Universidad de Salamanca, 37007 Salamanca, Spain;
[email protected] (H.B.-S.); [email protected] (A.A.-L.)
* Correspondence: [email protected]

Abstract: The skeletal and dental effects of rapid maxillary expansion (RME) have been extensively
studied, but high-quality research is still needed to determine the three-dimensional (3D) effects
of RME. The aim of this study was to compare skeletal and dentoalveolar parameters through
cone-beam computed tomography (CBCT) pre- (T1) and post-treatment (T2) with respect to RME.
Twenty growing patients (mean age 10.7 years) were treated with a Hyrax-type expander. A 3D
CBCT was performed at T1 and T2, measuring nasal width, maxillary width, palatal height, maxillary
Citation: Colino-Gallardo, P.; Del
arch perimeter, angulation of the upper first molar, and intermolar width. The mean palatal suture
Fresno-Aguilar, I.; Castillo-Montaño,
L.; Colino-Paniagua, C.;
opening was 2.85 ± 0.62 mm (p < 0.0001). Nasal width increased 1.28 ± 0.64 mm and maxillary width
Baptista-Sánchez, H.; Criado-Pérez, 2.79 ± 1.48 mm (p < 0.0001). In contrast, palatal height was reduced 0.65 ± 0.64 mm (p < 0.0001).
L.; Alvarado-Lorenzo, A. Skeletal and Regarding arch perimeter, the radicular perimeter increased 2.89 ± 1.80 mm, while the coronal
Dentoalveolar Changes in Growing perimeter increased 3.42 ± 2.09 mm (p < 0.0001). Molar angulation increased 5.62 ± 3.20◦ for the right
Patients Treated with Rapid molar and 4.74 ± 2.22◦ for the left molar (p < 0.0001). Intermolar width increased 5.21 ± 1.55 mm
Maxillary Expansion Measured in 3D (p < 0.0001). Treatment with Hyrax produced a significant opening in the mean palatal suture. Also, a
Cone-Beam Computed Tomography. significant increase in nasal width, maxillary width, arch perimeter, molar angulation, and intermolar
Biomedicines 2023, 11, 3305. https:// width, and a decrease in palatal height, were observed.
doi.org/10.3390/biomedicines
11123305
Keywords: rapid maxillary expansion; CBCT; growing patients; molar angulation; dentoalveolar;
Academic Editors: Angelo Michele orthodontics; skeletal change
Inchingolo, Gianna Dipalma,
Assunta Patano, Alessio Danilo
Inchingolo, Giuseppina Malcangi
and Francesco Inchingolo 1. Introduction
Received: 16 November 2023 Maxillary transverse deficiency and crowding in children are problems commonly
Revised: 8 December 2023 presented in orthodontic practices [1–4]. This palatal volume deficiency has been related to
Accepted: 12 December 2023 the volume of airways [5,6]. Patients with maxillary deficiency often have smaller nasal
Published: 13 December 2023 dimensions, tend to have greater resistance to airflow through the nose, and are often oral
breathers, when compared to patients with a normal maxillary arch [7].
Rapid maxillary expansion (RME) is a method widely used to correct crossbites and
maxillary deficiencies, especially as an early treatment in children [8–11]. In young adults,
Copyright: © 2023 by the authors.
however, RME is limited by the maturation of the suture, so other types of appliances are
Licensee MDPI, Basel, Switzerland.
commonly used to increase arch circumference, especially bone-borne appliances with
This article is an open access article
micro-screws [12–15].
distributed under the terms and
conditions of the Creative Commons
Clinical outcomes can often be different from what was anticipated. Frequently, when
Attribution (CC BY) license (https://
planning an RME, the midpalatal suture opening and the bone and dental tissue response
creativecommons.org/licenses/by/ have been expected based on the chronological age of the patient rather than the stage
4.0/). of suture maturation [16]. Patients show great variability in terms of the maturation of

Biomedicines 2023, 11, 3305. https://doi.org/10.3390/biomedicines11123305 https://www.mdpi.com/journal/biomedicines

Biomedicines 2023, 11, 3305 2 of 13

the midpalatal suture according to their chronological age [17,18]. This is why the use of
CBCT (Cone-Beam Computed Tomography) prior to planning a rapid expansion of the
maxilla is essential to determine the stage of the suture [19,20]. Hand–wrist X-rays [21]
and the cervical vertebrae maturation stage method (CVM) [18] are also reliable methods
commonly used to determine skeletal maturation.
Traditionally, studies about changes after RME have been based on occlusal radio-
graphs and frontal cephalometry, as these are the means commonly used in diagnosis and
during orthodontic treatment [22–26]. However, with the advent of CBCT, a more accurate
and replicable assessment of anatomical structures in all three planes of space has been
achieved [12–15,27–35]. On the other hand, there is an increasing interest in the evaluation
of dental and skeletal changes as well as changes in the nasal cavity after RME with CBCT
in growing patients [12,27–30,32,36–44]. However, most work in recent years has focused
mainly on studying volumetric changes [29,30,36,37,40,43,45], but it is also important to
analyze changes in linear dimensions that occur after RME [44].
The skeletal and dental effects of RME have been extensively studied [28,32,38,39,46–50],
but the heterogeneity and quality of the available studies do not provide sufficient evidence;
the correlation between dental and skeletal variables has not been sufficiently analyzed;
and randomized controlled trials are needed to determine the three-dimensional effects of
RME on the midpalatal suture [51]. Therefore, to date, information about the prediction of
RME outcomes remains limited [52].
The aim of this study was to evaluate the skeletal and dentoalveolar changes of
tooth-borne RME in growing patients in nasal and maxillary width, assessing changes at
the upper first molars and establishing arch perimeter differences at both radicular and
coronal levels.

2. Materials and Methods

2.1. Ethics Committee and Informed Consent
This research project was approved by the Bioethics Committee of the University
of Salamanca (USAL_20/516). The study followed the guidelines established by the
Declaration of Helsinki for research involving human subjects. All participants gave their
informed consent before they were included in the study.

2.2. Sample Size and Participants

A prospective clinical study was conducted on a sample of 20 patients, 11 women and
9 men. The mean age of the sample was 10.7 years, with the oldest patient being 15.8 years
old and the youngest 7.3 years old. The sample size was similar to those in previously
published studies [9,27,28,41–43].

2.3. Study Design

All patients were treated with a Hyrax expander, cemented in the upper first pre-
molars and upper first molars (Figure 1). If the first premolars had not yet erupted,
the Hyrax expander was cemented in the upper first deciduous molars and upper first
permanent molars.
The activation protocol was the same in all patients: 2 × 1/4 turns (0.2 mm) per day
until the desired sutural opening was obtained for each case, the average being about
15 days. A noticeable sutural opening was observed in all the patients in the sample,
produced by the appearance of an interincisal diastema. The appearance of this sign is an
expected result of treatment with RME, and it is accepted that there is a direct relationship
between the opening degree of the interincisal diastema and the amount of orthopedic
expansion [53].
Cone-beam computed tomographies (CBCT) were obtained before disjunction (T1)
and after disjunction (T2). The parameters measured in each CBCT of the maxilla were:
coronal arch perimeter (CP), root arch perimeter (RP), palatal height (PH), upper first molar
 Biomedicines 2023, 11, 3305 3 of 13

dicines 2023, 11, x FOR PEER REVIEW 3

angulation (MA), nasal base width (NBW), intermolar width (IMW), and maxillary width
(JR–JL).

FigureFigure
1. Hyrax tooth-borne
1. Hyrax tooth-borneexpanders with
expanders with 4 bands.
4 bands.

All participants met the following inclusion criteria: (1) Patients were included if they
The activation protocol was the same in all patients: 2 × 1/4 turns (0.2 mm) per
ranged in age from 7 to 15 years and were still growing according to the cervical vertebrae
until the desiredmethod
maturation sutural opening
of Baccetti was
et al. obtained
(2005) for each
[18]; (2) with case,
skeletal the average
maxillary compression;being abo
days. (3)
A noticeable suturalposterior
with uni- or bilateral opening was observed
crossbite; in all the
(4) with sufficient crown patients
eruptionin to the
allowsample,
cementation of the RME; (5) with no family relationship
duced by the appearance of an interincisal diastema. The appearance of this signto other patients participating
in the study; (6) at growth stages CS3 or lower of the midpalatal suture according to
expected resultclassification
Angelieri’s of treatment [54];with RME,ofand
(7) absence severeitcraniofacial
is accepted that there
syndromes is a direct relation
or malformations;
between the opening
(8) absence degreedisease;
of periodontal of the(9)interincisal diastema
without agenesis; and (10)and notthe amount
having received of orthop
previous
expansion orthopedic or orthodontic treatment.
[53].
Cone-beam
2.4. Procedure computed tomographies (CBCT) were obtained before disjunction
and after Thedisjunction (T2).were
study variables The measured
parameters by one measured
operator oninCBCT
eachimages
CBCTtaken of the
withmaxilla
a w
coronal arch 3D
GIANO perimeter
ADVANCED (CP), 13 × root arch perimeter
16 (WhiteFox, (RP), palatal
Satelec, Merignac, France)height
with the (PH), upper firs
following
exposure parameters: 105.0 kV, 105.0 kV peak, 8.0
lar angulation (MA), nasal base width (NBW), intermolar width (IMW), andmA, and 7.20 s, with a field of view of max
15 mm × 13 mm, and Anatomage Inc’s InVivo6 Dental software (Anatomage Europe,
widthMilan,
(JR–JL).Italy) was used to perform the measurements. Each variable was measured before
All
RME participants
(T1) and aftermet
RMEthe (T2).following inclusion criteria: (1) Patients were included if
ranged in Theagedentoalveolar
from 7 to 15variables
years and werewere
analyzed stillmeasured
growing as according
follows: to the cervical verte
maturation
1. method
Coronal of Baccetti
perimeter (CP): theet al. (2005)
distance between[18];
the(2) with
mesial skeletal
of the maxillary
right upper first molar compres
and the mesial of the left upper first molar, passing through
(3) with uni- or bilateral posterior crossbite; (4) with sufficient crown eruption to a the vestibular side of all
the teeth of the arch (Figure 2A).
cementation
2.
of the RME; (5) with no family relationship to other patients participati
Root perimeter (RP): the same procedure was used to measure the root perimeter but
the study;at(6) theat growth stages
amelocemental CS3
junction or(ACJ)
level lower [8] of the 2B).
(Figure midpalatal suture according to
gelieri’s
3. classification
Angulation of [54];
the upper(7) absence
first molarof(MA):
severe the craniofacial syndromes
angle formed between or malformat
a straight line
drawn parallel to the hard palate plane (in sagittal view, utilizing
(8) absence of periodontal disease; (9) without agenesis; and (10) not having received the anterior nasal
spine (ANS) and posterior nasal spine (PNS) as reference points) and a line passing
vious orthopedic
through theorcenter
orthodontic
of the pulptreatment.
chamber of both upper right and left first molars [12,55]
(Figure 2C).
2.4. Procedure
4. Intermolar width (IMW): the distance between the central fossa of the upper right
and left first molars was measured (Figure 2C).
The study variables were measured by one operator on CBCT images taken w
GIANO 3D ADVANCED 13 × 16 (WhiteFox, Satelec, Merignac, France) with the follo
exposure parameters: 105.0 kV, 105.0 kV peak, 8.0 mA, and 7.20 s, with a field of vie
15 mm × 13 mm, and Anatomage Inc’s InVivo6 Dental software (Anatomage Europe
lan, Italy) was used to perform the measurements. Each variable was measured b
RME (T1) and after RME (T2).
The dentoalveolar variables analyzed were measured as follows:
1. Coronal perimeter (CP): the distance between the mesial of the right upper first m
Biomedicines 2023, 11, x FOR PEER REVIEW 4 of 13

Biomedicines 2023, 11, 3305 4 of 13

4. Intermolar width (IMW): the distance between the central fossa of the upper right
and left first molars was measured (Figure 2C).

Figure 2. (A) Coronal perimeter (CP); (B) Root perimeter (RP); (C) Reference lines for palatal height
Figure 2. (A) Coronal perimeter (CP); (B) Root perimeter (RP); (C) Reference lines for palatal height
(PH), 1st molar angulation (MA), and intermolar width (IMW).
(PH), 1st molar angulation (MA), and intermolar width (IMW).

The skeletal
The skeletal variables
variables analyzed
analyzed were
were measured
measured as as follows:
follows:
1. Palatal height (PH): the distance from the midpalatal suture, tracing a perpendicu-
1. Palatal height (PH): the distance from the midpalatal suture, tracing a perpendicular
lar to the straight line formed from the central fossa of the right upper first molar to
to the straight line formed from the central fossa of the right upper first molar to the
the central fossa of the left upper first molar [56] (Figure 2C).
central fossa of the left upper first molar [56] (Figure 2C).
2. Sutural opening (SO): a straight line was drawn from the right- to the left edges of
2. Sutural opening (SO): a straight line was drawn from the right- to the left edges
the palatine
of the suture
palatine at the
suture at incisal level,level,
the incisal as thisasisthis
where the greatest
is where amountamount
the greatest of dis- of
junction occurs due to the fan-like opening pattern of the midpalatal
disjunction occurs due to the fan-like opening pattern of the midpalatal suture suture afterafter
disjunction [57] (Figure
disjunction [57] (Figure 3A).3A).
3.
3. Nasal
Nasal base
base width
width (NBW):
(NBW): the the most
most posterior
posterior cutcut of
of the
the nasal
nasal cavity
cavity was
was taken,
taken, and
and aa
straight line was drawn from right to left from the base of the nasal cavity
straight line was drawn from right to left from the base of the nasal cavity at its most at its
most inferior
inferior portion
portion [58] (Figure
[58] (Figure 3B). 3B).
4.
4. Maxillary
Maxillary width (JR–JL): the lowest
width (JR–JL): the lowest point
point ofof intersection
intersection ofof the
the zygomatic
zygomatic bone
bone with
with
the maxillary tuberosity was taken from the patient’s right (JR) to
the maxillary tuberosity was taken from the patient’s right (JR) to the patient’s the patient’s left
left
(JL)
(JL) [16]
[16] (Figure
(Figure 3C).
3C).
T1 and T2 values were determined, and the difference between these two values was
analyzed for each variable (Table 1).

Table 1. Comparison of dentoalveolar and skeletal variables studied at T1 and T2.

T1 T2 Difference
SD IC95% T p-Value D
(Mean) (Mean) T2–T1
Dentoalveolar variables
CP (mean) (mm) 82.97 86.4 3.42 2.09 [2.45–4.40] 7.34 <0.0001 ** 1.64
RP (mean) (mm) 80.48 83.33 2.89 1.80 [2.04–3.73] 7.18 <0.0001 ** 1.61
MA (mean) 99.41/ 105.03/ 5.62/ 3.20/ [4.12–7.11]/ 1.75/
7.84/9.56 <0.0001/<0.0001 **
(degree) 99.58 104.32 4.74 2.22 [3.70–5.78] 2.14
IMW (mean) (mm) 44.52 49.73 5.21 1.55 [4.48–5.93] 15.03 <0.0001 ** 3.36
 Biomedicines 2023, 11, 3305 5 of 13

Table 1. Cont.

T1 T2 Difference
SD IC95% T p-Value D
(Mean) (Mean) T2–T1
Skeletal variables
SO (mean) (mm) 0 2.85 2.85 0.62 [2.57–3.14] 20.84 <0.0001 ** 4.66
NBW (mean) (mm) 25.24 26.52 1.28 0.64 [0.98–1.57] 8.99 <0.0001 ** 2.01
PH (mean) (mm) 15.79 15.13 −0.65 0.64 [−0.95–−0.35] −4.56 <0.0001 ** 1.02
JR–JL (mean) (mm) 59.68 62.47 2.79 1.48 [2.10–3.48] 8.43 <0.0001 ** 1.89
Biomedicines 2023, 11, x FOR PEER REVIEW 5 of 13
SD: standard deviation. ** Statistically significant results (p < 0.01). CP: Coronal perimeter. RP: Root perimeter.
MA: Angulation of the 1st molar (right molar/left molar). IMW: Intermolar width. SO: Suture opening. NBW:
Nasal base width. PH: Palatal height. JR–JL: Maxillary width JR–JL.

Figure 3. (A)
Figure Suture
3. (A) Sutureopening;
opening; (B) Nasalbase
(B) Nasal basewidth;
width; (C)
(C) Maxillary
Maxillary width.
width.

2.5.T1Statistical
and T2 values
Analysiswere determined, and the difference between these two values was
analyzed for each variable (Table 1).
The data were analyzed using IBM SPSS Statistics (Version 29).
To determine a normal distribution of the variables, a Shapiro–Wilk test was performed,
Table
due1.toComparison of dentoalveolar
the small sample and skeletal
size. All variables variables
fit a normal studied atOnly
distribution. T1 and T2.differential
three
values (Dif_RP, Dif_NBW, and Dif_MA) have a significance level slightly below 0.050. Once
T1 T2 Difference
the normal distribution of theSDdata was IC95% T
verified, a Student’s p-Value
t-test for related samplesDwas
(Mean) (Mean) T2–T1
performed (Table 1). Levene’s test was conducted to compare the equality of variances
Dentoalveolar variables for gender differences (Table 2). Two levels of significance were established: p < 0.05 as
CP (mean) (mm) 82.97 86.4 significant and p2.09
statistically3.42 < 0.01 as[2.45–4.40]
statistically highly
7.34 significant.
<0.0001 ** 1.64
RP (mean) (mm) 80.48 83.33 2.89 1.80 [2.04–3.73] 7.18 <0.0001 ** 1.61
MA (mean) 99.41/ 105.03/ 5.62/ 3.20/ [4.12–7.11]/ 1.75/
7.84/9.56 <0.0001/<0.0001 **
(degree) 99.58 104.32 4.74 2.22 [3.70–5.78] 2.14
IMW (mean)
44.52 49.73 5.21 1.55 [4.48–5.93] 15.03 <0.0001 ** 3.36
(mm)
Skeletal variables
Biomedicines 2023, 11, 3305 6 of 13

Table 2. Gender comparison of changes at T2 in dentoalveolar and skeletal variables.

Male Mean Female Mean

p-Value
(SD) (SD)
3.51 3.34
DIF_CP 0.863
(1.95) (2.28)
2.35 3.32
DIF_RP 0.238
(1.59) (1.90)
1.06 1.45
DIF_NBW 0.178
(0.71) (0.53)
5.20 5.21
DIF_IMW 0.989
(1.64) (1.54)
−0.65 −0.65
DIF_PH 0.999
(0.58) (0.70)
DIF_MA 5.21 5.94
0.623
Right molar (3.62) (2.94)
DIF_MA 3.28 5.93
0.004 **
Left molar (1.95) (1.68)
2.68 2.87
DIF_JR–JL 0.789
(1.22) (1.71)
2.92 2.79
SO_T2 0.634
(0.53) (0.68)
SD: standard deviation. ** Statistically significant results (p < 0.01). CP: Coronal perimeter. RP: Root perimeter.
NBW: Nasal base width. IMW: Intermolar width. PH: Palatal height. MA: Angulation of the 1st molar (right
molar/left molar). JR–JL: Maxillary width JR–JL. SO: Suture opening.

3. Results
3.1. Differences between Measurements before RME (T1) and after RME (T2)
The mean age before treatment was 10.7 years and 11 years after treatment. On the
other hand, to study the changes in measurements over time, Table 1 shows the Student’s
t-test analyses for related samples. A statistically significant change was observed in all
variables (Table 1). Likewise, a statistically significant difference was observed between
males and females in left molar angulation, which was greater in females. However, the
rest of the variables showed no significant differences in terms of gender (Table 2).

3.2. Correlation between Variables

To study the relationship between the variables, Table 3 shows the Pearson correla-
tion matrix (or Spearman in the case of variables that do not comply with the normality
assumption).
Two main results are observed:
Changes in CP and RP present the highest correlation between variables (r = 0.626;
p < 0.01). In turn, changes in RP are related to JR–JL (r = 0.446; p < 0.05) and SO (r = 0.726;
p < 0.01). And changes in CP are related to SO (r = 0.726; p < 0.01). In summary, these
measures are positively related to each other, so an intervention on one of them implies an
intervention on the other ones.
IMW and MA are significantly correlated (r = 0.454; p < 0.05, and r = 0.488; p < 0.05),
so given an increasing IMW after intervention, MA has increased.
All transversal dental and skeletal variables showed a significant increase, indicating
that maxillary expansion was satisfactorily achieved.
Regarding the arch perimeter in T1 and T2, both at the radicular and coronal level,
both variables increased, which was also statistically significant (p < 0.0001 in both cases),
being also significantly correlated (r = 0.626; p < 0.01). On average, RP increased by
2.89 ± 1.80 mm, while CP increased by 3.42 ± 2.09 mm.
Biomedicines 2023, 11, 3305 7 of 13

Table 3. Correlation matrix between the differential variables under study.

Dif_ Dif_ Dif_ Dif_

AGE_T2 Dif_CP Dif_RP Dif_PH SO_T2
NBW IMW MA JR–JL
AGE_T2 1
Dif_CP −0.118 1
Dif_RP −0.189 0.626 ** 1
Dif_
−0.226 0.189 −0.058 1
NBW
Dif_
0.113 0.205 0.135 0.217 1
IMW
Dif_PH −0.099 −0.177 −0.242 −0.357 −0.434 1
−0.129/ −0.063/ −0.027/ −0.019/ 0.454 */ −0.234/
Dif_MA 1
0.067 0.066 0.200 0.319 0.488 * −0.257
Dif_ 0.091/
−0.029 0.317 0.446 * −0.037 0.346 −0.400 1
JR–JL 0.133
−0.029/
SO_T2 −0.165 0.558 * 0.726 ** 0.099 −0.080 −0.126 0.091 1
−0.057
SD: standard deviation. * Statistically significant results (p < 0.05). ** Statistically significant results (p < 0.01).
Spearman correlations are marked in italics. CP: Coronal perimeter. RP: Root perimeter. NBW: Nasal base width.
IMW: Intermolar width. PH: Palatal height. MA: Angulation of the 1st molar (right molar/left molar). JR–JL:
Maxillary width JR–JL. SO: Midpalatal suture opening.

Changes in JR–JL were related to RP but not to CP. Despite not finding a significant
correlation between JR–JL and CP, upon analyzing the regression model, it is estimated
that, for each millimeter gained in maxillary width (JR–JL), the CP increased by 0.45mm.
In relation to the upper first molars, the MA was significantly increased (p < 0.0001),
as was the IMW (p < 0.0001). The MA increased on average 5.62 ± 3.20◦ for the right
molar and 4.74 ± 2.22◦ for the left molar, in relation to the root–lingual torque, while the
IMW increased by 5.21 ± 1.55mm. Both variables have a significant relationship (r = 0.454;
p < 0.05, and r = 0.488; p < 0.05), where, according to Cohen’s statistic, the effect size was
larger for IMW (3.36) than for MA (1.75 right molar/2.14 left molar).
Both NBW and maxillary width (JR–JL) were statistically significantly increased
(p < 0.0001 in both cases). NBW increased, on average, 1.28 ± 0.64mm, while JR–JL
increased an average of 2.79 ± 1.48mm. Both measures are linearly independent so that
an increase in one of the parameters does not imply an increase in the other, and vice
versa. Likewise, a statistically significant reduction in PH was observed after expansion,
averaging 0.65 ± 0.64mm.
The mean palatal suture also increased significantly (p < 0.0001). The mean palatal
suture opening was 2.85 ± 0.62mm. This variable showed a significant relationship with
the increase in CP (r = 0.558; p < 0.05) and with the increase in RP (r = 0.726; p < 0.01).
Although there was no significant relationship between any of the variables and age,
there was a tendency (a negative correlation) for the change to be greater the younger the
age of the patients. This trend was observed in all the variables except for IMW and the left
molar angulation (MA).

4. Discussion
The effects of RME have been extensively studied [16,32,59–63]. The ratio between
the increase in transverse dimension and the dental changes resulting (arch perimeter,
intermolar width, etc.) are useful to help plan orthodontic treatments, as they are often
associated with the decision of whether or not to perform extractions. It is therefore of
interest to the clinician to know what dental changes occur with RME and how much space
can be gained in the dental arch with RME [8,9,59,64,65]. The size of the midpalatal suture
opening will depend on the occlusal needs of each patient. In our study, a mean midpalatal
suture opening (SO) of 2.85 ± 0.62mm was observed, which was statistically significant,
and we found that this SO was related to an increase in arch perimeter (CP and RP).
Biomedicines 2023, 11, 3305 8 of 13

- DENTOALVEOLAR CHANGES:
The measurement of molar angulations and intermolar width through CBCT is an
innovative way to analyze orthodontic cases from a more accurate point of view com-
pared to model analysis. RME generates changes in intermolar width (IMW), which in
our study was increased by 5.21 ± 1.55 mm, values that coincide with those observed in
most studies, which determine an increase of between 5.03mm and 6.7mm in intermolar
width [8,9,12,13,60,61,65–67]. On the other hand, these data vary greatly from those ob-
tained by Abdalla et al. (2019) [62], also due to measurement differences between studies,
although the results are similar in terms of perimeter increase after disjunction. Other
authors [16,59,62] also find an increase in intermolar width after RME, although slightly
lower than that obtained in our study, observing an increase of between 4mm and 4.87 mm,
and lower values are found by El and Palomo (2014) [30] and Canuto et al. (2010) [67],
with 2.9 mm in both studies, although still significant. On the other hand, Halicioglu et al.
(2010) [68] observed the highest values with an increase in intermolar width of 8.5mm.
These discrepancies in measurements between studies confirm the lack of standardization
of measurements.
Molar inclination has been described as a common side effect of RME [38,60,69–75]. In
our study, molar angulation (MA) increased on average 5.62◦ for the right molar and 4.74◦
for the left molar. Similar values were found by other authors [12,59], with an increase of
4.7–4.8◦ , and were slightly lower than those of Adkins et al. (1990) [8], with a change of 7.3◦ ,
although they also obtained a wide standard deviation, ± 5.8◦ , compared to 3.20/2.22◦
in our study. Other authors [60] obtained higher values, with 21◦ of molar angulation;
however, they do not take into account the angulation of each molar independently, so the
results are not comparable. In addition, we found that left molar angulation was higher in
females (5.93 ± 1.68◦ ) than in males (3.28 ± 1.95◦ ).
In our study, an increase in IMW is related with MA but not with maxillary width (JR–
JL), which could mean that RME produces mainly dental changes. Adkins et al. (1990) [8]
observed that, in patients with bilateral crossbite, a greater molar inclination occurs after
RME than in patients without crossbite because, at a certain time of the treatment, the
palatal slope of the palatal cusps of the maxillary teeth occludes with the vestibular slope
of the lingual cusps of the mandibular teeth, generating an occlusal force that favors the
buccal tip of the maxillary teeth.
RME also produces an increase in arch perimeter, both at the radicular and coronal
levels. The root perimeter (RP) increased by 2.89 ± 1.80mm, while the coronal perimeter
(CP) increased by 3.42 ± 2.09mm, where we obtained similar values to those observed in
other studies [8,9,62]. These parameters significantly correlated with each other and also
correlated directly with the opening of the midpalatal suture. Other authors found higher
values, with an increase of between 4.1mm and 5.05mm of CP [66,76]. McNamara et al.
(2003) [59] found even higher values, with a mean value of 6.3mm, and Aparecida et al.
(2006) [65] and Canuto et al. (2010) [67] found the lowest values, with a mean of 2.41mm
and 2.69mm of PC increase, respectively.
Knowing the proportion in which the maxillary width or intermolar width increases
with respect to the increase in CP, one could estimate the amount of spatial increase in arch
perimeter that we will obtain according to the amount of maxillary expansion performed.
Thus, for an average of 4.4mm of molar expansion, McNamara et al. (2003) [59] found a gain
of approximately 6mm in arch perimeter (CP). In our study, despite not finding a significant
correlation between the variables, by analyzing the regression model, it is estimated that, for
each millimeter gained in maxillary width, the arch perimeter increases by 0.45mm. Adkins
et al. (1990) [8] observed that the increase in arch perimeter can be predicted as 0.7 times
the amount of expansion performed; however, Berlocher et al. (1980) [64] observed an
increase of 1/1. These results can be used as a guideline for estimating the increase in the
perimeter after RME.
- SKELETAL CHANGES:
Biomedicines 2023, 11, 3305 9 of 13

Regarding the increase in maxillary width (JR–JL), Pereira et al. (2017) [60] ob-
tained an increase of 1.76 mm, slightly lower data figures than our results, where we
observed an increase of 2.79 ± 1.48 mm. The most similar data are found by Abdalla
et al. (2019) [62] and Sayar and Kılınç (2019) [16] with a 2.29–2.91 mm increase in maxillary
width. In contrast, El and Palomo (2014) [30] observe higher values of 3.5mm of increase in
maxillary width.
In previous studies [30,33,61], it has been observed that the size of the nasal structures
is affected by the expansion of the maxilla, and the nasal base width (NBW) increases
between 1.7mm and 2.39mm; in our study, we found similar values to those studies, with
an increase of 1.28 ± 0.64mm on average. The authors agree that the changes observed in
the studies are small, and the standard deviations are wide [8].
Kinzinger et al. (2022) [63] argue that the interaction of the different centers of rotation
of the palate during RME is the reason for the changes in palatal height and palatal shape
after RME. Especially the centers of rotation in the frontal plane, near the frontomaxillary
sutures, originate the rotation of the hard palate, which pivots laterally, generating an in-
crease in palatal height. However, in the present study, we observed a significant reduction
in palatal height (PH) after an expansion of 0.65 ± 0.65 mm on average. However, the way
the values were measured differed from one study to another.
To interpret all these data, it is necessary to take into account the natural growth
of the maxilla without RME treatment. It is difficult to quantify the amount of skeletal
expansion that is exclusively due to RME expansion because it is usually performed in
preadolescents, so the long-term effects are a combination of the treatment and the patient’s
natural growth [77]. What we knew until recently about maxillary growth was based
on older studies using implants, frontal cephalometry, and model analysis, with many
limitations [77–81]. However, Seubert et al. (2021) [77] confirm that the results obtained
in these studies are comparable to those obtained with the technological means currently
available (CBCT). Thus, the classic studies by Björk [78,79] estimated a transverse growth
of 0.42 ± 0.12 mm per year; Korn and Baumrind (1990) [80] observed a similar growth of
0.51 ± 0.16 mm per year; and recent studies with CBCT [77] confirm an annual transverse
growth of 0.50 ± 0.31 mm. Regarding nasal width, Seubert et al. (2021) [77] observed an
increase of 0.3mm per year. All this indicates that a small part of the growth observed in
any growing sample is due to the normal growth of the patient.
When comparing these values with those observed in studies using different expan-
sion appliances, studies using mini-screw-assisted rapid palatal expansion (MARPE) or
surgically assisted rapid palatal expansion (SARPE) found similar values to those found
in our study with RME, with 5.34–5.8 mm of IMW increase [12,82], while other studies
found lower values of 3.70–4.91 mm [13,14]. The higher values of IMW increase were
observed by Altug et al. (2006) [83] with 7.81 for both RME and SARPE groups, and other
studies showed lower increases of 0.98–2.2mm using slow maxillary expansion (SME)
appliances [33,35]. On the other hand, it was observed that MA was lower in studies using
MARPE and SARPE [12,14,15,82], except for Altug et al. (2006) [83] who found higher MA
in the SARPE group than in the RME group, and the MA had higher values in the SME
group when comparing it to the RME group [33], although their MA values in the RME
group were lower than in our study. Regarding the skeletal parameters, studies found
the higher increases in the NBW with MARPE and SARPE and the lowest increases with
SME [12,14,15,33]. Similar values to those observed in our study for maxillary width (JR–JL)
and SO with RME were observed in studies with MARPE and SARPE [12,15,83]. However,
we have to keep in mind the lack of standardization of measurements when interpreting
these differences or similarities between studies. Some studies also evaluate alveolar bone
changes after expansion with different outcomes, which would be interesting to include in
future investigations [12,14,15,34,35].
- LIMITATIONS OF THIS STUDY:
This study has a number of limitations. Although the measurements have shown
significant differences, the sample size is small. Also, a comparison with patients without
Biomedicines 2023, 11, 3305 10 of 13

growth could be carried out, as the lack of a control group makes it difficult to know
whether the observed changes are due to a patient’s own growth or to the effect of RME.
On the other hand, the lack of standardization of CBCT measurements makes it difficult to
compare between similar studies, which coincides with what has been observed in other
analyses [51]. The method error has not been assessed. The measurements studied can be
reproduced but could differ according to the operator, due to the fact that the establishment
of reference points on the CBCT is not automatic, and the operator must choose where to
place them. For this reason, there could be an increase in inter- and intra-operator error
when the same cases are studied.

5. Conclusions
According to the results observed in the present study, we can conclude that tooth-
borne RME produces an increase in nasal width and maxillary width and also in the
radiculo–lingual torque of the upper molars and in the intermolar width. Tooth-borne RME
also produces an increase in arch perimeter, both at the coronal and the radicular level.
Although there is no significant relationship with the increase in the coronal perimeter,
the increase in maxillary width shows a tendency to increase in a proportion of 1/0.45 in
relation to the increase in coronal perimeter (JR–JL/CP). This may serve as an estimation of
the space that can be gained after RME.

Author Contributions: Conceptualization, P.C.-G. and A.A.-L.; methodology, P.C.-G.; software,

C.C.-P.; validation, P.C.-G. and A.A.-L.; formal analysis, L.C.-M.; investigation, I.D.F.-A. and L.C.-P.;
resources, P.C.-G.; data curation, H.B.-S.; writing—original draft preparation, I.D.F.-A., L.C.-P. and
A.A.-L.; writing—review and editing, L.C.-P. and A.A.-L.; visualization, H.B.-S.; supervision, L.C.-P.
and A.A.-L.; project administration, P.C.-G. and A.A.-L.; funding acquisition, A.A.-L. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: This study was conducted in accordance with the Declaration
of Helsinki and approved by the Bioethics Committee of the University of Salamanca (USAL_20/516).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data are only available on request, due to restrictions, e.g., privacy
or ethical.
Conflicts of Interest: The authors declare no conflict of interest.

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