Original Article

Transverse dentoalveolar response of mandibular arch after rapid maxillary

expansion (RME) with tooth-borne and bone-borne appliances:
A CBCT retrospective study

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Antonino Lo Giudicea; Vincenzo Ronsivalleb; Manuel Lagraverec; Rosalia Leonardid;
Stefano Martinae; Gaetano Isolaf

ABSTRACT
Objectives: To assess and compare spontaneous expansion of mandibular posterior teeth
between tooth-borne (TB) and bone-borne (BB) rapid maxillary expansion (RME).
Materials and Methods: This study included 36 adolescents with bilateral maxillary crossbite
receiving tooth-borne (average age: 14.4 6 1.3 years) or bone-borne (average age: 14.7 6 1.4
years) maxillary expansion. Cone beam computed tomography was acquired before expansion
(T1) and after 6 months’ retention (T2). Specific linear and angular measurements were performed
in the coronal view to assess buccal inclinations and widths of mandibular posterior units. All data
were statistically analyzed.
Results: In both groups there was a significant increase in buccal-lingual inclination of mandibular
posterior teeth ranging from 1.678 to 2.308 in the TB group and from 1.468 to 2.118 in BB group.
Mandibular posterior widths showed an increase ranging from 0.80 mm to 1.33 mm in TB group and
from 0.64 mm to 0.96 mm in the BB group. No differences between groups were found for linear or
angular measurements.
Conclusions: A clinically significant gain of space in the mandibular arch should not be expected
after RME. (Angle Orthod. 0000;00:000–000.)
KEY WORDS: RME; Tooth-borne RME; Bone-borne RME; Arch expansion; Dentoalveolar effects

INTRODUCTION
Skeletal and dentoalveolar effects of rapid maxillary
expansion (RME) have been widely investigated and
a
Adjunct Professor, Department of Orthodontics, School of confirmed by the highest levels of scientific evi-
Dentistry, University of Catania, Catania, Italy.
b
Research Fellow, Department of Orthodontics, School of dence.1–3 However, little is known about the potential
Dentistry, University of Catania, Catania, Italy. dentoalveolar effects of RME in the mandibular arch.
c
Professor, Orthodontic Graduate Program, University of The assumption has been that expansion of the
Alberta, Edmonton, Alberta, Canada. maxillary dental arch could induce functional upright-
d
Full Professor and Department Chair, Department of
Orthodontics, School of Dentistry, University of Catania, Catania,
ing of mandibular posterior teeth.4–7 This may have
Italy. clinical relevance concerning the indication for man-
e
Adjunct Professor, School of Dentistry, University of Naples dibular dental arch expansion.
Federico II, Naples, Italy. Some studies8,9 have confirmed, while others have
f
Assistant Professor, Department of Oral Surgery and
refuted,10,11 the spontaneous increase in lower inter-
Periodontology, School of Dentistry, University of Catania,
Catania, Italy. molar and intercanine widths after expansion of the
Corresponding author: Antonino Lo Giudice, DDS, PhD, MSc, maxillary arch, and no definitive consensus was
Department of Orthodontics, School of Dentistry, University of reached.12 Previous investigations8–11 were performed
Catania, Policlinico Universitario ‘‘Vittorio Emanuele,’’ Via Santa using conventional dental casts without the evaluation
Sofia 78, Catania 95123, Italy
(e-mail: [email protected]) of the buccal-lingual inclination of the roots or were
biased since quantitative data were obtained after
Accepted: May 2020. Submitted: March 2020.
Published Online: July 14, 2020 completion of fixed orthodontic therapy.12 Only one
Ó 0000 by The EH Angle Education and Research Foundation, previous study13 was conducted using cone beam
Inc. computed tomography and showed that maxillary and

DOI: 10.2319/042520-353.1 1 Angle Orthodontist, Vol 00, No 00, 0000

2 LO GIUDICE, RONSIVALLE, LAGRAVERE, LEONARDI, MARTINA, ISOLA

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Figure 1. Tooth-borne (A) and Bone-borne (B) palatal expander used in this study.

mandibular posterior dental units tipped buccally lower posterior dental units (first premolar, second
immediately after RME, with slight relapse in the upper premolar, first molar), (6) no artifacts, (7) no temporo-
arch and further expansion in the lower arch during the mandibular joint disorder, (8) no previous orthodontic
follow-up period.13 treatment, (9) no craniofacial anomalies or systemic
Previous evidence confirmed that skeletal anchor- diseases. Eighteen subjects in the TB group (10
age can increase the skeletal effect of RME, extending females, eight males; mean age: 14.4 6 1.3 years)
the benefits of this therapy to late adolescence and and 18 subjects in the BB group (12 females, six
adulthood.14–16 Also, it appeared that bone-borne RME males; mean age: 14.7 6 1.4 years) were included in
limited the tipping of maxillary posterior teeth.14,17 the study.
However, no studies have assessed the potential In the TB group, subjects received a Hyrax expander
effects of bone-borne RME on the mandibular arch with bands on the permanent first molars and first
compared to conventional tooth-borne RME. premolars. In the BB group, two miniscrews were
The aim of the present study was to assess the inserted in the palate between the permanent first
transverse changes (buccal-lingual inclinations and molar and the second premolar (length: 12 mm;
transverse widths) of mandibular posterior dental units diameter: 1.5 mm; Straumann GBR System, Andover,
after RME and to make comparative analyses between MA) and connected with the expander (Palex II Extra-
two groups of subjects treated with tooth- and bone- Mini Expander, Summit Orthodontic Services, Munroe
borne maxillary expanders. The null hypothesis was Falls, OH; Figure 1B). In both groups, the activation
that there would be no differences in post-treatment rate of the jackscrew was 0.25 mm/turn and the RME
changes in the lower arch between tooth-borne (TB) protocol included two turns per day, for a total of 0.5
and bone-borne (BB) groups. mm/d. Activations were stopped once overexpansion
was achieved, ie, when the mesiopalatal cusps of the
MATERIALS AND METHODS maxillary first molars were in contact with the buccal
The present study was approved by the Institutional cusps of the mandibular first molars. The appliance
Review Board of Indiana University–Purdue University was kept in place for 6 months as retention and, during
(IRB protocol number: 1708606623) and included a this period, patients did not receive other orthodontic
retrospective sample of adolescents with a diagnosis of appliances either in the upper or lower arch.
skeletal transverse deficiency treated with tooth-borne Cone beam computed tomography (CBCT) was
(TB group) or bone-borne (BB group) RME as part of performed on all subjects before expansion (T1) and
their comprehensive orthodontic therapy (Figure 1). after the 6 months of retention (T2). Patients were
Inclusion criteria for the present study were as follows: scanned with the same iCAT CBCT Unit (Imaging
(1) age between 11 and 16 years, (2) full permanent Sciences International, Hartfield, PA). The setting
dentition (except for third molars), (3) posterior cross- protocol included 0.3 mm voxel, 8.9 seconds, and
bite without mandibular functional shift in centric large field of view at 120 kV and 20 mA. The distance
occlusion, (4) CBCT scans of good quality taken prior between 2 slices was 0.3 mm, which provided
to the placement of the maxillary expander (T1) and accuracy in anatomic registration.
after its removal (6 months) (T2), (5) no caries, dental Buccal-lingual inclinations of maxillary and mandib-
restorations, or endodontic therapy of the upper and ular posterior teeth were assessed at T1 and T2 by

Angle Orthodontist, Vol 00, No 00, 0000

MANDIBULAR DENTOALVEOLAR RESPONSE AFTER RME 3

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Figure 2. Head re-orientation on axial, sagittal and coronal plane of CBCT scans. The 3D image shows the head orientation in 3D space. Lines
represent the reference axes.

using the CWRU’s transverse analysis method.18 Statistics

Although this method was reported for measuring the
Sample size calculation was performed using data
inclinations of first molars and canines, application was
from a previous study.13 The analysis showed that 18
extended for this study to the measurements of first
subjects were required for each treatment group to
and second premolars. Upper and lower canines were
detect a mean difference of 0.688 in the angular
excluded from the examination since most of the
measurement of mandibular first molars between T1
included subjects presented ectopic displacement of
these teeth. After head orientation (Figure 2),9 a and T2, with a power of 80% and a significance level of
reference line was drawn tangent to the nasal floor 0.05.
and the buccal-lingual inclinations of maxillary teeth The normal distribution and equality of variance of
were calculated by measuring the angle between this the data was performed with Shapiro-Wilk Normality
line and the palatal long axis of each tooth (Figure 3). Test and Levene’s test. When data showed normal
For mandibular measurements, a reference line was distribution and equality of variance, the following
drawn tangent to the inferior border of the mandible parametric tests were used: Paired Student’s t-test
and the buccal-lingual inclinations of mandibular teeth for intra-group comparison between T1 and T2
were calculated by measuring the angle between this measurements, Independent Student’s t-test for be-
line and the long axis of each tooth (Figure 4). Internal tween-groups comparison of the T1-T2 differences.
widths of maxillary and mandibular posterior units were When data did not show a normal distribution, the
also evaluated at T1 and T2 by choosing the most following non-parametric tests were used: Wilcoxon
occlusal reference points of the right and left palatal signed-rank test for intra-group comparison between
cusps (mesiopalatal cusps for the lower first molars) T1 and T2 measurements, and Mann-Whitney U-test
(Figures 3 and 4). for between-group comparisons of the T1-T2 differ-
The entire measurement workflow was performed by ences. Linear regression was performed to investigate
a single expert examiner (A.L.G.) who processed only a cause-effect relationship between expansion of the
2 CBCT scans each day to avoid fatigue and who was maxillary posterior units (independent variable) and
blinded regarding the type of appliance used. CBCT expansion of the mandibular posterior units (depen-
records of 10 subjects were randomly selected to dent variable).
calculate intra-observer variability and the method Intra-examiner reliability was assessed using intra-
error. The entire process was repeated 4 weeks later class correlation coefficient (ICC) while analysis of the
by the same researcher, with no knowledge of the first method error was performed using Dahlberg’s formu-
measurements. la.20 Data sets were analyzed using SPSS version 24

Angle Orthodontist, Vol 00, No 0, 0000

4 LO GIUDICE, RONSIVALLE, LAGRAVERE, LEONARDI, MARTINA, ISOLA

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Figure 3. Example of measurement procedure for the maxillary first molars.

Statistics software (IBM Corporation, Armonk, New the increase in maxillary linear measurements (predic-
York, USA). tor variable). In both the TB and BB groups, the
increase in mandibular intermolar widths showed
RESULTS strong (0.826) and good (0.716) correlations, respec-
tively, with maxillary expansion (increase in maxillary
TB and BB groups showed a statistically significant
intermolar width).
increase of buccal-lingual inclinations of upper and
Finally, the ICC values showed excellent correlations
lower posterior teeth (P , .001) (Tables 1 and 2). In
between the two readings for angular measurements
the maxillary arch, these increases were significantly
(0.871 to 0.992) and for linear measurements (0.925 to
greater in the TB group for each tooth investigated (P
0.995). The random error ranged from 0.058 to 0.148 for
values  .001) (Table 1). In the mandibular arch, the
angular measurements and from 0.06 mm to 0.10 mm
increases did not differ between the two groups,
for linear measurements (Dahlberg’s formula).
except for the right and left first premolars (P , 005)
(Table 2).
DISCUSSION
Similarly, TB and BB groups showed a statistically
significant increase in all posterior widths (linear mea- The present CBCT study was the first that assessed
surements) examined in the maxilla (P , .001) and in the changes of buccal-lingual inclinations and changes of
mandible (P , .001). There were no differences in transverse widths of mandibular posterior dental units
amount of expansion between the two groups, except for in two groups of subjects treated with tooth-borne and
the measurements made between the mandibular first bone-borne palatal expanders.
premolars (P , .05) (Table 3). Before discussing the data obtained in the mandib-
Table 4 shows the linear regression values between ular arch, a brief summary of the changes recorded in
the increase in mandibular linear measurements and the maxillary arch is necessary. Both groups showed

Angle Orthodontist, Vol 00, No 00, 0000

MANDIBULAR DENTOALVEOLAR RESPONSE AFTER RME 5

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Figure 4. Example of measurement procedure for the mandibular first molars.

an increase of buccal-lingual inclinations of maxillary significant. All of the subjects included in this study
posterior teeth, with subjects in the TB group showing experienced successful correction of their cross-bite
greater changes compared to the BB group. This was either with tooth-borne or bone-borne expanders.
in agreement with previous findings reporting greater Previously published data from the same study
tipping of posterior teeth with tooth-borne expanders.21 sample22 showed greater skeletal opening of the
The intermolar and interpremolar widths also increased midpalatal suture using the bone-borne expander; the
after RME, with subjects in the TB group showing small differences in the dento-alveolar expansion
slightly greater increases compared to the BB group, found between the two groups would compensate for
though the difference between groups was not the differences in the skeletal changes.14

Table 1. Maxillary Angular Measurements Before (T1) and After Rapid Maxillary Expansion (T2) for Each Investigated Tooth: Intra-Group
Comparisons And Inter-Group Comparisons (Mean Differences)a
Inter-groups Comparisons
Intra-group Comparisons (mean differences)
TB Group BB Group
T1 T2 T1 T2 TB Group BB Group
Maxillary Angular
Measurements (8) N Mean SD Mean SD Significance N Mean SD Mean SD Significance Mean SD Mean SD Significance
16 18 96.42 1.99 99.07 2.31 P , .001* 18 98.10 3.60 98.70 4.12 P , .001** 2.66 0.58 0.60 0.58

15 18 93.48 2.06 94.67 2.07 P , .001* 18 92.26 2.39 92.79 2.80 P , .001* 1.19 0.27 0.53 0.49 P , .001^^
14 18 89.47 0.93 92.97 1.12 P , .001* 18 93.11 1.90 93.35 2.10 P , .001** 3.51 0.50 0.24 0.27 P , .001^^
26 18 98.84 2.69 101.06 3.10 P , .001** 18 99.83 4.38 100.62 4.73 P , .001** 2.22 0.85 0.78 0.62 P , .001^
25 18 91.81 1.52 92.79 1.61 P , .001** 18 91.57 3.13 92.22 2.80 P , .001** 0.98 0.35 0.64 0.52 P , .001^^
24 18 90.41 1.36 94.44 2.60 P , .001* 18 92.03 1.80 92.36 1.90 P , .001** 4.03 1.44 0.33 0.29 P , .001^^
a
TB indicates tooth-borne group; BB, bone-borne group; N, sample size; SD, standard deviation.
* Significance set on P , .05, according to the paired Student’s t-test; ** Significance set on P , .05, according to the Wilcoxon signed-rank
test; ^ Significance set at P , .05, according to the Independent Student’s t-test; ^^ Significance set at P , .05, according to the Mann-Whitney U
test.

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6 LO GIUDICE, RONSIVALLE, LAGRAVERE, LEONARDI, MARTINA, ISOLA

Table 2. Mandibular Angular Measurements Before (T1) and After Rapid Maxillary Expansion (T2) for Each Investigated Tooth: Intra-Group
Comparisons and Inter-Groups Comparisons (Mean Differences)a
Inter-groups Comparisons
Intra-group Comparisons (mean differences)
TB Group BB Group
T1 T2 T1 T2 TB Group BB Group
Maxillary Angular
Measurements (8) N Mean SD Mean SD Significance N Mean SD Mean SD Significance Mean SD Mean SD Significance
46 18 75.87 2.09 77.76 2.07 P , .001** 18 76.47 1.80 78.36 2.17 P , .001* 1.88 0.55 1.89 0.90 NS
45 18 77.48 2.00 79.28 2.14 P , .001** 18 76.20 3.11 77.83 2.88 P , .001** 1.81 0.57 1.63 0.85 NS

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44 18 83.47 1.32 85.77 1.44 P , .001* 18 79.77 0.91 81.23 1.13 P , .001* 2.30 0.55 1.46 0.73 P , 0.05^^
36 18 74.45 1.24 76.38 1.66 P , .001* 18 77.21 2.35 79.33 1.99 P , .001** 1.93 0.88 2.11 0.92 NS
35 18 80.46 1.96 82.13 2.17 P , .001* 18 78.80 1.51 80.23 1.57 P , .001* 1.67 0.94 1.43 0.73 NS
34 18 85.98 1.17 88.00 1.36 P , .001* 18 81.30 1.34 82.60 0.86 P , .001* 2.02 0.69 1.30 0.71 P , 0.05^
a
TB indicates tooth-borne group; BB, bone-borne group; N, sample size; SD, standard deviation.
* Significance set on P , .05, according to the paired Student’s t-test; ** Significance set on P , .05, according to the Wilcoxon signed-rank
test; ^ Significance set at P , .05, according to the Independent Student’s t-test; ^^ Significance set at P , .05, according to the Mann-Whitney U
test.

The buccal-lingual inclinations of the mandibular the TB group. These findings could be attributed to the
posterior teeth increased slightly after RME, with the design of the Hyrax expander that was anchored also
lower molars almost reaching an increase of 28 in the to the upper first premolars, causing greater tipping of
TB and BB groups. Similarly, the intermolar and these teeth (see notably greater values compared to
interpremolar widths showed a small increase after the upper second premolars) and, as a consequence,
RME that ranged from 0.80 mm for the second similar effects on the antagonist lower first premolars
premolars to 1.33 mm for the first premolars in the due to potential occlusal interferences occurring during
TB group, and from 0.71 mm for second premolars to the expansion.
0.96 mm for first premolars in the BB group. All these The hypothesis that expansion of the maxillary arch
findings were in agreement with previous evidence could modify the equilibrium of forces between the
obtained from a sample of subjects treated with tooth- tongue and cheeks could explain the present findings
borne expanders.13 No differences were found in the as well as previous evidence.12 In particular, maxillary
angular and linear changes of mandibular first molars expansion could cause buccinator muscles to move
and second premolars between the two groups, away from the lower arch (lip bumper-like effect),
suggesting that the different pattern of expansion of favoring tongue forces that would be responsible for
the upper arch between tooth-borne and bone-borne uprighting of the lower posterior teeth, as found in the
appliances (skeletal sutural opening, dental tipping, present study.4,5 Baysal et al.13 found that mandibular
bending of the alveolar processes), still to be com- transverse widths increased immediately after RME
pletely clarified,14 did not affect the spontaneous but also after the retention period, supporting that there
response of mandibular arch. However, a small was an initial, spontaneous decompensation of the
significant difference between the two groups was lower arch following RME and a subsequent, slower
found in the measurements of the lower first premolars, uprighting during the retention period caused by the lip-
with post-treatment tipping and expansion greater in bumper-like effect. In the present study, CBCT scans

Table 3. Maxillary and Mandibular Linear Measurements Before (T1) and After Rapid Maxillary Expansion (T2) for Each Investigated Tooth:
Intra-Group Comparisons and Inter-Groups Comparisons (Mean Differences)
Inter-groups Comparisons
Intra-group Comparisons (mean differences)
TB Group BB Group
Linear T1 T2 T1 T2 TB Group BB Group
Measurements
(mm) N Mean SD Mean SD Significance N Mean SD Mean SD Significance Mean SD Mean SD Significance
Maxilla 16–26 width 18 36.40 3.48 40.60 3.35 P , .001* 18 35.34 2.90 38.36 4.28 P , .001* 4.20 1.39 3.02 1.48 NS
15–25 width 18 33.24 2.42 36.35 2.84 P , .001* 18 32.37 3.16 35.17 2.75 P , .001* 3.12 1.19 2.80 0.75 NS
14–24 width 18 26.61 1.79 30.56 1.96 P , .001* 18 24.71 2.09 27.82 1.80 P , .001* 3.94 1.18 3.11 1.12 NS
Mandible 36–46 width 18 31.98 2.70 33.06 3.12 P , .001* 18 33.13 3.43 34.09 3.60 P , .001* 1.08 0.69 0.96 0.60 NS
35–45 width 18 28.39 2.25 29.19 2.53 P , .001* 18 31.39 1.89 32.10 2.26 P , .001* 0.80 0.54 0.71 0.91 NS
34–44 width 18 22.89 3.32 24.22 2.67 P , .001* 18 24.17 2.19 24.81 2.52 P , .001* 1.33 0.74 0.64 0.47 P , 0.05^
a
TB indicates tooth-borne group; BB, bone-borne group; N, sample size; SD, standard deviation; NS, not significant.
* Significance set on P , .05, according to the Wilcoxon signed-rank test; ^ Significance set at P , .05, according to the Mann-Whitney U test.

Angle Orthodontist, Vol 00, No 00, 0000

MANDIBULAR DENTOALVEOLAR RESPONSE AFTER RME 7

Table 4. Linear Regression Tests Model Using Maxillary Width Measurements as Independent Variables (Predictor) and Mandibular Width
Measurements as Dependent Variables
Coefficients 95% Interval Coefficient (B)
Dependent Predictor Standard Lower Upper
Groups Variables Variables R R Squared Beta Error Limit Limit
TB 36–46 width 16–26 width 0.826 0.628 0.826 0.070 0.261 0.558
35–45 width 15–25 width 0.570 0.325 0.570 0.093 0.061 0.455
34–44 width 14–24 width 0.562 0.316 0.562 0.130 0.078 0.631
BB 36–46 width 16–26 width 0.716 0.513 0.716 0.071 0.141 0.442

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35–45 width 15–25 width 0.415 0.172 0.415 0.276 0.082 1087,000
34–44 width 14–24 width 0.528 0.279 0.528 0.088 0.033 0.408

were taken after removal of the palatal expander (six protocol. If expansion of the mandibular dentition is
months after RME) and both described hypotheses needed, it must be done using specific biomechanic
could have contributed to the findings. strategies within the lower arch.12
To test the cause-effect relationship between chang-
es in the upper and lower arches, a regression analysis Limitations
was performed using the increase in maxillary width as
a predictor variable. The results of linear regression The absence of a control group was the main
tests indicated a significant correlation only between limitation of the present study. Expansion by normal
the upper and lower first molars in both the TB and BB growth may have affected quantitative data in both
groups. These findings may be interpreted considering treated groups. However, considering that data were
that the first molars were the teeth most involved in the obtained after short-term evaluation (6 months),23 this
cross-bite relationship. When two opposing teeth are in limitation could be considered negligible.
a cross-bite relationship, greater occlusal interferences The present findings did not consider subjects with
can be generated during maxillary expansion, which different skeletal patterns. Several studies reported a
may have resulted in greater expansion of the relationship between vertical skeletal pattern and
antagonist lower teeth.23 In this regard, bonded muscle activity or occlusal forces.25–29 These differenc-
expander appliances were recommended in those es may also affect the mandibular dentoalveolar
cases in which decompensation of the lower arch response after RME due to different intensities of
was not required, since the acrylic plane eliminated occlusal contacts.
these interferences.24 With this notion in mind, it could
be postulated that, during maxillary expansion, when CONCLUSIONS
first molars are in a cross-bite relationship, the two  RME caused slight buccal inclination and a slight
buccal cusps may generate greater interferences at the
increase in the intra-arch widths between mandibular
lower molar fossa and along the sloped lingual aspect
of the buccal cusps, favoring buccal movement of the posterior teeth.
antagonist lower first molars. This assumption may
 Post-RME treatment changes in the lower arch did
explain previous evidence of the immediate response not differ between TB and BB groups. Thus, the null
of the mandibular molars after maxillary expansion,13 hypothesis of the present study was not rejected.
however rejecting the hypothesis of ‘‘spontaneous’’  From a clinical perspective, considering the small
mandibular uprighting. Taking this assumption with amount of post-treatment expansion in the mandible,
caution, well-designed prospective clinical trials, in- clinicians should not expect to see a clinically
volving different areas of cross-bite as recruitment significant gain of space in the lower arch after RME.
variables, even using non-invasive methods such as
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