ORIGINAL ARTICLE

Comparison of the treatment effects of

different rapid maxillary expansion
devices on the maxilla and the mandible.
Part 1: Evaluation of dentoalveolar
changes
Selin Canana and Neslihan Ebru Şenışıkb
Izmir and Isparta, Turkey

Introduction: The aim of this study was to compare the dentoalveolar treatment effects of 3 rapid maxillary
expansion (RME) appliances, supported by different tissues, on the maxilla and the mandible. Methods:
Patients were assessed for eligibility, and those who met the requirements and agreed to participate were
enrolled in the study. Participants were randomly allocated into 3 groups, depending on the type of expansion.
The tooth-borne group (n 5 16; ages, 12.63 6 1.36 years) had RME with a tooth-borne appliance; the
bone-borne group (n 5 16; ages, 12.92 6 1.07 years) had RME with a bone-borne appliance; and the hybrid
group (n 5 15; ages, 13.41 6 0.88 years) had RME with hybrid appliances. Dentoalveolar effects were
evaluated by digitally superimposed 3-dimensional scans of maxillary dental casts on a coordinate system
and linear interdental width measurements of mandibular dental casts in the pretreatment, posttreatment, and
postretention periods. For intragroup and intergroup comparisons, 1-way analysis of variance for repeated
measures and multivariate analysis of variance were performed, respectively. Results: Similar dentoalveolar
treatment effects were achieved in all groups with the exception of a small amount of expansion on the right
side in the bone-borne group. Conclusions: All 3 expanders led to the expansion of maxillary dentoalveolar
structures with mild relapse. However, the amount of expansion of the bone-borne expander on the right side
was statistically lower. Spontaneous interdental expansion was observed in the mandibular dentitions in all
groups. (Am J Orthod Dentofacial Orthop 2017;151:1125-38)

T
ransverse discrepancy between the dental arches supporting structures that are used as force application
arising from maxillary constriction can be points can affect treatment results at the dentoalveolar
eliminated with rapid maxillary expansion (RME) level.4-7 Some RME devices with different designs that
treatment.1 The force generated by the RME appliance provide sutural expansion can cause undesired side
and applied through the maxillary teeth and alveolar effects on maxillary teeth during RME treatment.4,8,9
process or the palatal vault exceeds the resistance of Thus, the most appropriate RME device should be used
maxillary sutural articulations; thus, the maxillary to eliminate adverse effects. A hyrax screw soldered to
palatal suture separates, and skeletal expansion bands is the most frequently used RME appliance for
begins.1-3 In the design of the RME device, the crossbite treatment.10 Because of the common compli-
cations of tooth-borne RME devices, such as extrusion
a
Private practice, Izmir, Turkey.
of posterior teeth and buccal tilting of anchored teeth,9
b
Department of Orthodontics, Faculty of Dentistry, S€uleyman Demirel University, the use of bone-borne devices that apply the force
Isparta, Turkey. directly through the bone with skeletal anchorage units
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
has been recommended.4,11,12 However, crown tipping
Address correspondence to: Neslihan Ebru Şenışık, Department of Orthodontics, of maxillary posterior teeth in the palatal direction as a
Faculty of Dentistry, S€ uleyman Demirel University, Isparta, Turkey; e-mail, counterforce against the expansion was reported with
[email protected].
Submitted, August 2016; revised and accepted, November 2016.
bone-borne expanders that are designed without tooth
0889-5406/$36.00 support.8 Instead, it has been stated that hybrid RME
Ó 2017 by the American Association of Orthodontists. All rights reserved. devices, designed with both skeletal anchorage and
http://dx.doi.org/10.1016/j.ajodo.2016.11.022

1125
1126 Canan and Şenışık

Assessed for eligibility (n=58)

Enrollment Excluded (n=5)

 Not meeting inclusion criteria (n=0)
 Declined to participate (n=4)
 Other reasons (n=1)

Randomized (n=53)

Allocation

Tooth-Borne Group (TBG) Bone-Borne Group (BBG) Hybrid Group (HG)

Allocated to intervention (n=18) Allocated to intervention (n=18) Allocated to intervention (n=17)
 Received allocated intervention (n=18)  Received allocated intervention (n=17)  Received allocated intervention (n=17)
 Did not receive allocated intervention (n=1)
(family’s request)

Follow-Up

Lost to follow-up (failed to keep up the Lost to follow-up (moved) (n=1) Lost to follow-up (give up the study in
appointments) (n=1) retention period) (n=1)
Discontinued intervention (cooperation loss) Lost to follow-up (failed to keep up the
appointments) (n=1)

Analysis

Analyzed (n=16) Analyzed (n=16) Analyzed (n=15)

Fig 1. Flow diagram of patients in the study.

tooth support, can reduce the side effects of tooth-borne MATERIAL AND METHODS
devices5,6,13 and provide better periodontal status.14 To This study was performed in the Department of Ortho-
the best of our knowledge, it is unclear whether any of dontics, Faculty of Dentistry, of S€ uleyman Demirel Uni-
these 3 expander types is superior based on evidence versity in Isparta, Turkey. The study was approved by
at the dentoalveolar level because of the lack of compar- the ethics committee of the Republic of Turkey, Ministry
ative clinical studies in similar age groups with the same of Health, Pharmaceuticals and Medical Devices Agency
protocol and amount of expansion. (71146310, 2013-AC-CE-28). Written informed consent
At present, the superimposition of 3-dimensional was obtained from all subjects. The inclusion criteria for
(3D) digital maxillary dental models is used to assess participants were (1) unilateral or bilateral transverse
treatment efficiency at the dentoalveolar level.15,16 maxillary deficiency between 5 and 10 mm, (2) skeletal
After superimposition, maxillary dentoalveolar changes Class I relationship, (3) normal vertical height, (4) perma-
can be assessed using x, y, and z coordinates by nent dentition, (5) chronologic age between 12 and
evaluating the dental models in the time intervals.16,17 15 years, (6) no periodontal disease, and (7) no other or-
This method is preferred since it is noninvasive and thodontic treatment. As a result of preliminary work for
reliable.17 Three-dimensional digital maxillary dental this study, the sample size was calculated. Required sam-
model superimpositions allow us to determine alter- ple size for 80% power was 15 patients per group (for the
ations at the regional level. mesiobuccal cusp tip of the maxillary right first molar:
The aim of this study was to compare the dentoalveo- mean, –24.41; SD, 1.5; alpha level, 0.05). We found 58
lar treatment effects of tooth-borne, bone-borne, and patients who fulfilled the criteria and were assessed for
hybrid RME appliances on the obtained 3D digital dental eligibility in 2012 and 2013. After the research period,
models of the maxilla and the mandible at 3 time inter- the data of 47 subjects (25 girls, 22 boys) were analyzed
vals. The null hypothesis was that there are no statistically in this study (Fig 1). Three study groups were designated [F1-4/C]
significant differences in the treatment effects of these with stratified randomization (strata, sex) according to
appliances involving tooth-borne (hyrax), bone-borne, the type of expander used: the tooth-borne group
and hybrid RME devices, on the maxillary and mandibular (TBG), comprising 8 girls and 8 boys, had RME with a
dentoalveolar structures in adolescent patients.

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Table I. Distribution of age, expansion amount, active expansion duration, retention duration, and total treatment
duration for the groups
TBG (n 5 16) BBG (n 5 16) HG (n 5 15)

X 6 SD Min Max X 6 SD Min Max X 6 SD Min Max

Chronologic age (y) 12.63 6 1.36 10.08 14.17 12.92 6 1.07 10.25 14.67 13.41 6 0.88 11.83 14.75
Expansion amount (mm) 6.59 6 1.28 4.5 9.0 6.22 6 0.66 5.5 8.0 7.07 6 1.25 5.5 9.0
Active expansion duration (d) 13.31 6 2.78 9.0 19.0 12.44 6 1.31 11.0 16.0 14.13 6 2.50 11.0 18.0
Retention duration (mo) 6.14 6 0.30 5.80 6.97 5.95 6 0.23 5.43 6.37 6.13 6 0.26 5.47 6.63
Total treatment duration (mo) 6.76 6 0.53 6.33 8.00 6.64 6 0.50 6.00 8.13 6.80 6 0.45 5.93 8.07

TBG, Tooth-borne group; BBG, bone-borne group; HG, hybrid group; X, mean; Min, minimum; Max, maximum.

Fig 2. Expansion appliances: A, tooth-borne appliance (hyrax); B, bone-borne appliance; in the design
of the bone-borne device, the mini-implants were inserted to similar places as with the tooth-borne de-
vice (between the first and second premolars, and between the second premolars and first molars on
the palatal slope, bilaterally). To obtain easy clinical implementation and tight placement for bone-borne
expanders in the BBG, the expansion screw was opened 10 quarter turns, and then the arms of the
expansion screw were bent in the laboratory process. The arms of the expansion screw were soldered
to the caps of the mini-implants on the plaster model. Before applying the device, the screw was fully
closed, cement material was filled in to the caps, and the appliance was placed on the mini-implants in
the mouth. Then the expansion screw was opened 10 quarter turns, and tight placement was achieved.
C, hybrid appliance (the mini-implants were inserted between the first and second premolars, and 2
bands were placed, bilaterally on the first molars, as in the tooth-borne device; the caps of the mini-
implants and bands were soldered to the arms of the expansion screw).

tooth-borne appliance; the bone-borne group (BBG), Seoul, Korea) were used. Similar insertion and force
comprising 9 girls and 7 boys, had RME with a bone- application points of anchorage units for these 3 devices
borne appliance; and the hybrid group (HG), comprising were selected to apply similar force vectors. After the
8 girls and 7 boys, had RME with a hyrax tooth-borne fabrication, glass ionomer cement (Meron; Voco, Cux-
appliance and a bone-borne appliance (Table I). haven, Germany) was used for cementing the bands
In the TBG, the tooth-borne expander (hyrax and caps directly.
appliance) was designed with bands on the maxillary first In all groups, the expansion screw was activated by 2
[F2-4/C] premolars and first molars (Fig 2, A). In the BBG, the quarter turns per day in the active treatment process
bone-borne expander was supported with 4 mini- (0.25 mm per turn, 0.5 mm daily). After a sufficient
implants. Easy clinical implementation18 and tight amount of expansion in each patient, the expansion
placement of the appliance were achieved (Fig 2, B). In screw was fixed. The retention period was 6 months.
the HG (tooth and bone-borne appliance, hybrid hyrax), The treatment durations, active expansion amounts,
mini-implants and molar bands were used bilaterally expansion durations, and total treatment times for the
(Fig 2, C). In all groups, the same brands of expansion groups are given in Table I.
screw (9 mm; Lewa-Dental, Remchingen, Germany) Dental casts were taken at 3 times: pretreatment, after
and mini-implant (1.8 3 9 mm, predrilling; Yesanchor, the appliance was bonded (T0); posttreatment, after the

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Fig 3. Superimpositions of 3D digital maxillary dental models: A, T0-T1; B, T1-T2; C, T0-T2. Yellow,
T0; red, T1; gray, T2.

Fig 4. Coordinate system: the origin point 0 (x 5 0, y 5 0, z 5 0) and the x-, y-, and z-planes. Before
measuring the changes of selected points between time intervals, the coordinate system was estab-
lished on each pretreatment 3D digital model (T0) at the intersection of the incisive papilla and the me-
dian palatine raphe, and this point was identified as the origin point. Then the x-, y-, and z-axes and
related planes were reconstructed.

activation period (T1); and postretention, after 6 months and T2 (A2 [x2, y2, z2]). The alterations at selected
of retention (T2). Three-dimensional digital dental points in millimeters were measured using the
models in all periods were obtained from the dental casts coordinate system (Fig 5). Comparisons of the treatment [F5-4/C]
of all subjects using an orthodontic model scanner (R700; modalities and the positions of the selected points were
3Shape A/S, Copenhagen, Denmark). The reconstruction, made according to the transverse (x-axis), vertical (y-
superimposition, and computation of the 3D digital axis), and anteroposterior (z-axis) planes, separately. To
models were performed using 3D reverse modeling soft- determine alterations in the tipping angle of the posterior
ware (version 1.01; Orthomodel, _Istanbul, Turkey). Super- teeth, angular changes were measured with logarithmic
imposition of the 3D maxillary digital models at the 3 time calculations at the 3 time points on the superimpositions
intervals (T0, T1, T2) was performed on the median points (Fig 5). The angle between y-axis and a line created with
of the third palatal rugae, which can be used as a reliable the coordinates of the buccal and palatinal cusp tip points
[F3-4/C] landmark (Fig 3).16,19 The coordinate system (Fig 4) of a tooth were logarithmically calculated. Mandibular
established using the maxillary pretreatment model was dentoalveolar changes were measured with linear inter-
[F4-4/C] transferred to the maxillary superimpositions.20,21 The dental width measurements on mandibular 3D digital
positional changes of each selected point obtained by dental models at T0, T1, and T2 (Fig 5).
the treatment modalities between time intervals was After an interval, study models of 16 patients were
identified according to this coordinate system in 3 randomly chosen, and selected points were remarked
dimensions of space; thus, each point had different and identified in the coordinate system in the maxilla,
coordinates at T0 (A0 [x0, y0, z0]), T1 (A1 [x1, y1, z1]), and interdental width measurements were repeated in

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the mandible for reproducibility of the measurements.

Reproducibility was assessed by the Pearson correlation
coefficient (r minimum 5 0.982). Data were processed
with the Statistical Package for Social Sciences, (version
15.0; SPSS, Chicago, Ill). The normal distribution of the
data was assessed with the Kolmogorov-Smirnov Z-
test, and a normal distribution was found for all fea-
tures. A chi-square test of homogeneity was used to
determine whether the distribution of the sexes was
similar in the groups. A t test was used to examine
the differences between the mean values of the boys
and girls according to age, amount of expansion, active
expansion duration, retention time, and total observa-
tion period. Because there were no statistically signifi-
cant differences between the mean values for the sexes
(P .0.05), the sex factor was excluded from the model.
The statistical intergroup differences of treatment ef-
fects of the 3 RME appliances were compared by multi-
variate analysis of variance. Intragroup differences were
assessed with 1-way analysis of variance for repeated
measures, and the least significant difference test was
used for post hoc comparisons. Values of P \0.05
were considered significant.

RESULTS
Complications such as broken orthodontic appliances
or loosened mini-implants were reported and eliminated
immediately (Table II). The mean values of the study
groups with regard to age, treatment duration, amount
of active expansion, duration of expansion, and total
Fig 5. Measurement points and angles for maxillary su- treatment time did not show any statistically significant
perimpositions. A, Measurement points: 1, UR1, mesioin- difference (P \0.05) (Table I).
cisal edge of the maxillary right central incisor; 2, UL1, For the maxillary superimpositions, there were no
mesioincisal edge of the maxillary left central incisor; 3, intergroup differences (Table III) in the anterior region.
UR3, cusp tip of the maxillary right canine; 4, UL3, cusp The maxillary right and left central incisors (UR1-x,
tip of the maxillary left canine; 5, UR4B, buccal cusp tip UL1-x) and canines (UR3-x, UL3-x) moved distally after
of the maxillary right first premolar; 6, UR4P, palatinal the active expansion period (T1), and relapse occurred
cusp tip of the maxillary right first premolar; 7, UL4B,
after retention (T2) in both groups. There were no statis-
buccal cusp tip of the maxillary left first premolar; 8,
UL4P, palatinal cusp tip of the maxillary left first premolar;
tically significant differences between groups (P .0.05).
9, UR6MB, mesiobuccal cusp tip of the maxillary right first In the posterior region, the right first premolar (UR4B-x,
molar; 10, UR6MP, mesiopalatinal cusp tip of the maxil- UR4P-x) significantly moved more buccally in the TBG
lary right first molar; 11, UL6MB, mesiobuccal cusp tip
of the maxillary left first molar; 12, UL6MP, mesiopalatinal
cusp tip of the maxillary left first molar; B, angular mea- indicate extrusive tooth movement. Increased values
surements: 13, maxillary right premolar-a; 14, maxilalry along the z-axis indicate protrusive tooth movement,
left premolar-a; 15, maxillary right molar-a; 16, maxillary and decreased values indicate retrusive tooth movement.
left molar-a. According to the coordinate system in the For angular measurements, increased values indicate
x-axis, positive values indicate the patient's left side, crown tipping to the buccal side (outward tipping). C,
and negative values indicate the right side. For the left Mandibular interarch width measurements: 17, LR3-
side, increased values indicate expansion (distal) move- LL3, interarch width between the mandibular canines;
ment; for the right side, decreased values indicate expan- 18, LR4-LL4, interarch width between the mandibular first
sion (distal) movement. Increased values along the y-axis premolars; 19, LR6-LL6, interarch width between the
indicate intrusive tooth movement, and decreased values mandibular first molars.

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(T1-T2), buccal movement of the buccal cusp tip of the

Table II. Distribution of observed complications ac-
maxillary left first premolar (UL4B-x) continued in the
cording to groups during the study period
HG. Relapse occurred regarding the posterior (distal)
TBG BBG HG movement of the maxillary left first premolar (UL4B-z,
(n 5 16) (n 5 16) (n 5 15) UL4P-z), which moved mesially. In both groups, the
Broken premolar/molar band 4 – 0 new buccal positions (T0-T2) of the first premolars
Loosened mini-implant – 2 0
Loosened appliance 6 4 1
(UR4B-x, UR4P-x, UL4B-x, UL4P-x) were more signifi-
Broken appliance 2 1 2 cant than the initial position, except for the palatinal
Transpalatal arch application in 0 3 0 cusp of the maxillary left first premolar in the HG.
retention period During expansion (T0-T1), the maxillary first molars
TBG, Tooth-borne group; BBG, bone-borne group; HG, hybrid (UR6MB-x, UR6MP-x, UL6MB-x, UL6MP-x) signifi-
group. cantly moved buccally in both groups. The mesiobuccal
cusp tips of the maxillary first molars (UR6MB-y,
UL6MB-y) were significantly intruded in the TBG. In
than in the BBG (P\0.05) at T1; this difference persisted the retention period (T1-T2), the mesiopalatinal cusp
at T2. The right first molar (UR6MB-x, UR6MP-x) signif- tip of the maxillary right first molar (UR6MP-y) intruded
icantly moved more buccally in the TBG and the HG than and moved mesially (UR6MP-z) in the TBG. However,
in the BBG (P \0.01) after the active expansion period the maxillary right first molar (UR6MB-x, UR6MP-x)
(T1). This difference increased after retention. moved palatinally in the BBG. The mesiopalatinal cusp
For the maxillary superimposition, there were intra- tip of the maxillary right first molar (UR6MP-y) intruded
group differences (Tables IV-VI) during the active in the HG. With treatment (T0-T2), first molars (UR6MB-
expansion period (T0-T1). The maxillary central incisors x, UR6MP-x, UL6MB-x, UL6MP-x) significantly moved
(UR1-x, UL1-x) moved distally except for the maxillary buccally (P \0.001) except for the maxillary right first
right central incisors in the BBG. In the TBG and BBG, molar (UR6MB-x, UR6MP-x) in the BBG. The mesiobuc-
the maxillary central incisors (UR1-z, UL1-z) signifi- cal cusp tips of the maxillary first molars (UR6MB-y and
cantly moved palatinally. During the retention period UL6MB-y) were significantly intruded with treatment in
(T1-T2), the diastema between the maxillary central in- the TBG.
cisors (UR1-x, UL1-x) was closed with mesial movement In the T0-T1 period, the outward tiltings of the
in both groups (P \0.05). The maxillary central incisors maxillary first premolars (UR4-a, UL4-a) in the TBG
were positioned more mesially (UR1-x, UL1-x) and were and (UR4-a) in the HG, and the maxillary first molars
more retruded (UR1-z, UL1-z) compared with the initial (UL6-a) in the TBG and (UR6-a, UL6-a) in the HG
locations (T0-T2). were significantly increased. During retention (T1-T2),
The maxillary canines (UR3-x, UL3-x) moved distally significant uprighting of first premolars (UL4-a) and first
in both groups during expansion (T0-T1). After molars (UR6-a, UL6-a) in the HG were obtained. With
the retention period (T1-T2), these canines moved signif- treatment (T0-T2), the outward tilting of the maxillary
icantly mesially except for the maxillary left canines in the left first premolar and maxillary left first molar in the
HG and the maxillary right canines in the BBG. In the HG, TBG and the maxillary right first molar in the HG
the maxillary canines (UR3-y, UL3-y) were significantly increased significantly.
extruded (P \0.01). The new mesial positions (T0-T2) There were no statistically significant intergroup dif-
of the maxillary left canines (UL3-x) were statistically sig- ferences for mandibular interdental width changes be-
nificant in the TBG and the BBG. In the HG, the maxillary tween groups (Table III). Regarding intragroup
canines (UR3-y, UL3-y) were more extruded compared differences, mandibular intermolar width (LL6M-
with the initial positions (P \0.05). LR6M) was significantly increased in all groups in the
The maxillary first premolars (UR4B-x, UR4P-x, UL4B- T0 to T1 period. This alteration significantly increased
x, UL4P-x) significantly moved buccally in both groups. in the T1 to T2 period in the TBG and the BBG. After
The amount of buccal movement was less on the right the retention period, the obtained mandibular intermo-
side (P \0.01) than on the left side (P \0.001) in the lar width was significantly wider than the initial mea-
BBG. The palatinal cusp tips of the maxillary left first pre- surements (T0-T2) in all groups (Tables IV-VI).
molar (UL4P-y) were significantly extruded after expan-
sion in the TBG and the HG (P \0.05, P \0.01, DISCUSSION
respectively). After the retention period (T1-T2), the pala- In this study, the clinical complications were fewer in
tinal cusp tip of the maxillary right first premolar (UR4P- the HG, probably due to the design of the hybrid appli-
y) was intruded in the TBG (P \0.01). During retention ance (Table II). A loss of stability in the bone-borne RME

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Table III. Descriptive statistics and intergroup differences of the 3 groups at T0, T1, and T2
Pretreatment (T0) Posttreatment (T1) Postretention (T2)

TBG (n 5 16) BBG (n 5 16) HG (n 5 15) TBG (n 5 16) BBG (n 5 16) HG (n 5 15) TBG (n 5 16) BBG (n 5 16) HG (n 5 15)

X 6 SD X 6 SD X 6 SD P X 6 SD X 6 SD X 6 SD P X 6 SD X 6 SD X 6 SD P
Maxillary superimposition measurements
UR1-x 0.86 6 0.84 1.08 6 0.38 0.92 6 0.62 NS 1.13 6 1.52 0.79 6 0.51 1.48 6 1.57 NS 0.25 6 1.30 0.01 6 1.05 0.42 6 1.59 NS
UR1-y 3.88 6 2.45 4.27 6 1.60 4.15 6 0.98 NS 4.16 6 2.55 4.21 6 1.60 4.48 6 1.02 NS 3.75 6 2.29 3.87 6 1.71 4.16 6 1.22 NS
UR1-z 6.53 6 1.23 6.61 6 2.10 6.73 6 1.00 NS 5.89 6 1.29 6.31 6 2.12 6.25 6 1.07 NS 5.90 6 1.52 6.02 6 2.09 6.02 6 1.42 NS
UL1-x 1.56 6 0.60 0.89 6 0.62 1.09 6 0.78 NS 3.32 6 1.29 2.90 6 1.14 2.66 6 1.76 NS 2.02 6 1.18 1.79 6 1.06 1.49 6 1.63 NS
UL1-y 4.05 6 2.48 4.26 6 1.55 3.72 6 1.81 NS 4.28 6 2.47 4.46 6 1.60 4.11 6 1.74 NS 3.92 6 2.35 3.80 6 1.69 3.80 6 1.87 NS
UL1-z 6.06 6 0.96 6.78 6 2.21 6.79 6 1.55 NS 5.66 6 1.16 6.13 6 2.19 6.48 6 1.49 NS 5.58 6 1.25 6.11 6 2.24 6.41 6 1.44 NS
UR3-x 15.88 6 1.19 16.14 6 1.73 16.41 6 1.74 NS 16.68 6 1.58 16.19 6 2.01 17.40 6 2.54 NS 16.04 6 1.40 15.77 6 1.63 16.46 6 2.24 NS
UR3-y 2.76 6 2.86 2.77 6 3.49 2.53 6 2.39 NS 2.90 6 2.82 2.90 6 3.47 2.36 6 2.44 NS 3.15 6 2.60 2.55 6 3.39 3.12 6 2.59 NS
UR3-z 1.44 6 2.18 0.76 6 3.25 0.09 6 2.33 NS 1.72 6 2.36 0.71 6 3.22 0.10 6 2.52 NS 1.45 6 2.35 0.34 6 3.11 0.37 6 2.64 NS
UL3-x 16.31 6 1.90 16.41 6 1.36 16.19 6 1.58 NS 18.44 6 2.02 18.55 6 1.38 17.75 6 2.36 NS 17.77 6 1.94 17.61 6 1.57 17.32 6 2.09 NS
UL3-y 1.77 6 2.51 3.00 6 2.76 2.33 6 3.56 NS 1.92 6 2.67 3.16 6 3.03 2.45 6 3.94 NS 2.63 6 2.16 3.37 6 3.02 3.25 6 3.85 NS
UL3-z 0.60 6 3.50 0.66 6 2.30 0.65 6 2.97 NS 1.36 6 3.97 1.48 6 2.44 1.05 6 4.07 NS 1.18 6 3.64 0.99 6 2.84 1.04 6 3.43 NS
UR4B-x 18.20 6 2.12 18.08 6 1.76 18.54 6 1.86 NS 20.32 6 2.14 b 18.55 6 1.75 a 19.76 6 2.01 ab * 20.34 6 2.22 b 18.44 6 1.91 a 19.49 6 1.94 ab *
UR4B-y 4.12 6 2.78 4.66 6 1.76 4.09 6 2.04 NS 4.07 6 2.53 4.73 6 1.70 4.18 6 1.95 NS 3.93 6 2.49 4.47 6 1.82 4.27 6 2.07 NS
UR4B-z 8.99 6 2.32 8.22 6 3.42 7.93 6 1.97 NS 8.82 6 2.27 8.22 6 3.48 8.31 6 2.28 NS 8.81 6 2.33 7.91 6 3.43 8.64 6 2.60 NS
UR4P-x 13.30 6 1.92 13.13 6 1.66 13.43 6 1.70 NS 15.22 6 1.96 b 13.51 6 1.67 a 14.61 6 1.75 ab * 15.34 6 1.95 b 13.56 6 1.79 a 14.40 6 1.71 ab *
UR4P-y 3.29 6 2.50 4.13 6 1.52 3.29 6 1.60 NS 3.63 6 2.29 4.17 6 1.55 3.69 6 1.56 NS 3.33 6 2.25 4.01 6 1.71 3.68 6 1.65 NS
UR4P-z 10.26 6 2.13 9.37 6 2.90 9.44 6 1.61 NS 10.41 6 2.33 9.54 6 2.99 9.64 6 1.94 NS 10.02 6 2.25 9.13 6 2.88 10.18 6 2.28 NS
UL4B-x 18.49 6 1.91 18.71 6 1.47 19.09 6 2.05 NS 21.32 6 1.92 20.68 6 1.55 20.60 6 2.07 NS 21.66 6 2.14 20.49 6 1.57 20.60 6 2.42 NS
UL4B-y 3.93 6 2.20 4.73 6 1.37 3.89 6 2.15 NS 3.82 6 2.04 4.91 6 1.48 4.15 6 2.19 NS 3.60 6 2.07 4.70 6 1.64 4.42 6 2.21 NS
UL4B-z 8.73 6 3.77 8.20 6 2.23 8.01 6 3.05 NS 9.40 6 4.05 9.03 6 2.59 8.67 6 3.89 NS 9.28 6 3.72 8.43 6 3.00 8.78 6 3.31 NS
UL4P-x 13.65 6 1.84 13.54 6 1.53 14.02 6 1.91 NS 16.46 6 2.00 15.68 6 1.55 15.52 6 1.86 NS 16.59 6 2.12 15.49 6 1.55 15.43 6 2.32 NS
UL4P-y 3.03 6 2.11 4.10 6 1.11 2.98 6 1.78 NS 3.42 6 1.97 4.36 6 1.35 3.46 6 2.01 NS 3.19 6 2.02 4.20 6 1.41 3.55 6 2.10 NS
UL4P-z 10.01 6 3.01 9.52 6 2.24 9.52 6 3.02 NS 10.80 6 3.50 10.35 6 2.60 10.04 6 3.84 NS 10.52 6 3.11 9.87 6 2.95 10.26 6 3.27 NS
y
UR6MB-x 23.32 6 1.85 23.08 6 2.83 23.25 6 2.63 NS 25.62 6 1.50 b 23.82 6 2.67 a 25.71 6 2.66 b * 25.51 6 1.64 b 23.34 6 2.35 a 26.07 6 2.32 b
UR6MB-y 3.12 6 2.67 3.36 6 1.76 3.18 6 1.88 NS 2.79 6 2.41 3.26 6 1.57 2.85 6 1.84 NS 2.69 6 2.42 3.30 6 1.70 2.79 6 2.06 NS
UR6MB-z 22.37 6 2.30 20.84 6 3.46 21.31 6 1.94 NS 22.28 6 2.35 21.01 6 3.55 21.20 6 2.69 NS 22.04 6 2.43 20.72 6 3.31 21.18 6 3.11 NS
June 2017
Vol 151
Issue 6

UL6MB-x 23.75 6 1.76 24.31 6 2.30 24.12 6 2.01 NS 26.25 6 2.38 26.23 6 2.16 26.44 6 2.25 NS 26.58 6 2.12 25.83 6 1.97 26.95 6 2.49 NS
UL6MB-y 2.70 6 2.07 3.40 6 1.22 2.95 6 1.81 NS 2.14 6 2.11 3.46 6 1.32 2.78 6 1.96 NS 2.00 6 2.04 3.55 6 1.45 2.63 6 2.22 NS
UL6MB-z 22.11 6 4.10 20.74 6 2.56 21.19 6 3.16 NS 22.80 6 4.49 21.80 6 2.92 21.39 6 3.93 NS 22.78 6 4.30 21.23 6 3.69 21.31 6 3.32 NS
y
UR6MP-x 18.56 6 2.10 18.04 6 2.91 18.27 6 2.74 NS 20.91 6 1.86 b 18.71 6 2.64 a 21.00 6 2.76 b * 20.82 6 1.95 b 18.30 6 2.34 a 21.22 6 2.45 b
UR6MP-y 3.74 6 2.50 4.12 6 1.93 3.68 6 1.57 NS 3.77 6 2.44 4.17 6 1.74 4.05 6 1.59 NS 3.46 6 2.45 4.01 6 1.85 3.68 6 1.62 NS
UR6MP-z 25.85 6 2.41 24.14 6 3.49 24.47 6 2.10 NS 25.77 6 2.46 24.39 6 3.64 24.65 6 2.52 NS 25.45 6 2.51 23.99 6 3.38 24.50 6 3.03 NS
UL6MP-x 19.16 6 1.86 19.37 6 2.60 19.08 6 2.00 NS 21.76 6 2.39 21.26 6 2.40 21.67 6 2.16 NS 21.90 6 2.35 20.85 6 2.12 22.13 6 2.41 NS
UL6MP-y 3.24 6 2.00 3.92 6 1.46 3.58 6 1.74 NS 3.30 6 2.07 4.34 6 1.22 3.85 6 2.01 NS 2.99 6 2.10 4.21 6 1.27 3.44 6 2.21 NS
UL6MP-z 25.66 6 3.85 24.12 6 2.46 24.23 6 2.93 NS 26.47 6 4.27 24.90 6 2.91 24.66 6 3.62 NS 26.06 6 3.91 24.33 6 3.56 24.40 6 3.29 NS
UR4-a 81.13 6 6.77 83.86 6 9.44 80.26 6 7.39 NS 85.37 6 6.84 83.81 6 8.85 83.34 6 6.18 NS 83.36 6 7.12 84.69 6 8.13 82.43 6 5.81 NS

1131
1132 Canan and Şenışık

device by tongue movements and pressure in the BBG

NS
NS
NS

NS
NS
NS
P
was mentioned by some patients. In RME treatment,
rotational movement of the maxillary halves occurs
HG (n 5 15)

80.66 6 7.06
98.58 6 7.19
97.98 6 3.81

27.80 6 1.91
34.44 6 2.58
44.29 6 3.60
X 6 SD
due to 2 centers of rotation, which are located at the
frontonasal suture from the frontal view and at the pos-
terior of the midpalatal suture in the third molar area,
from the occlusal view.22 A pyramid-shaped expan-
Postretention (T2)

sion—ie, widening in the anterior region and base, nar-

Intergroup differences are indicated with lowercase letters, a and b. There were no statistically significant differences between the means with the same letters (P .0.05).
BBG (n 5 16)

83.80 6 6.48
96.63 6 6.47
96.55 6 7.44

24.47 6 6.81
33.52 6 3.05
42.96 6 2.74
rowing as the midpalatal suture goes superiorly and
X 6 SD

posteriorly—has been produced in both the frontal and

occlusal views of the suture.23,24
In this study, the maxillary central incisors extruded,
retracted, and moved distally with the maxillary halves;
TBG (n 5 16)

86.43 6 6.71
97.87 6 6.84
99.70 6 3.37

26.99 6 2.03
34.20 6 3.40
44.14 6 2.93

this is the result of rotational expansion movement,

X 6 SD

except for UR1-x in the BBG. This retraction movement

occurred because of the triangular-shaped opening
movement of the maxillary halves that was wider in
the anterior region. Because the palate region is reliable
NS
NS
NS

NS
NS
NS
P

in the superimposition method of 3D digital maxillary

models, even in patients treated with RME, this soft tis-
HG (n 5 15)

82.68 6 7.34
101.59 6 7.59
100.32 6 3.40

27.61 6 2.08
34.13 6 2.59
43.75 6 3.67
X 6 SD

sue area remains stable during opening of the maxillary

halves, but the bony structures do not.21 With this
expansion movement, the bony structures of the maxil-
Posttreatment (T1)

lary halves and accompanying structures such as teeth

move distally and posteriorly, resulting in the retracted
BBG (n 5 16)

85.22 6 7.89
98.36 6 5.14
98.38 6 5.41

24.75 6 6.91
33.68 6 3.05
42.39 6 2.40

position of the maxillary incisors compared with the

X 6 SD

TBG, Tooth-borne group; BBG, bone-borne group; HG, hybrid group; X, mean; NS, not significant.

initial positions in the occlusal view (Fig 6). In the reten- [F6-4/C]
tion period, the retracted position of the maxillary cen-
tral incisors persisted during their mesialization
(relapse). Extrusion was obtained in the maxillary central
NS 85.67 6 10.53
TBG (n 5 16)

NS 99.33 6 5.39
NS 101.08 6 4.23

26.85 6 2.03
33.75 6 2.98
43.80 6 2.93

incisors. In a finite element method study, Jafari et al25

X 6 SD

showed that the lateral structures moved upward,

whereas the midline structures and the maxillary incisors
were displaced downward after RME because of rotation
NS
NS
NS

of the nasomaxillary complex. The effects of both appli-

P

ances on the maxillary central incisors were statistically

80.23 6 9.57 83.81 6 6.85 80.55 6 8.91
96.03 6 4.92 97.17 6 4.42 95.10 6 6.04
95.32 6 4.70 98.01 6 5.50 96.01 6 3.47

26.67 6 1.84 24.66 6 6.86 27.49 6 2.00

33.77 6 2.89 33.48 6 3.04 34.01 6 2.64
43.43 6 2.83 42.11 6 2.31 43.44 6 3.45
HG (n 5 15)

similar (Table III). This result agrees with the litera-

*P \0.05; yP \0.01 (multivariate analysis of variance value).
X 6 SD

ture.7,26 However, Lagravere et al7 did not report the

retraction of maxillary central incisors in a study in which
Mandibular ıntermaxillary arch width measurements
Pretreatment (T0)

the skeletal and dentoalveolar differences were evalu-

BBG (n 5 16)

ated together on cone-beam computed tomography im-

X 6 SD

ages. A possible reason for this discrepancy could be the

methodologic differences between these studies.
Generally, expansion, extrusion, and retraction were
obtained for the maxillary canines. These changes were
TBG (n 5 16)

maintained with mild relapse. In the BBG, the mean

X 6 SD
Table III. Continued

value of distal movement of the maxillary right canine

(UR3-x) was low between T0 and T1. Maxillary canine
eruption was incomplete in some patients in our sample;
thus, possible reasons for this extrusion movement could
LL3-LR3
LL4-LR4
LL6-LR6
UR6-a
UL4-a

UL6-a

be tooth eruption, in addition to rotation of the naso-

maxillary complex in the vertical plane. The positional
changes of the maxillary canines were similar regarding

June 2017
Vol 151
Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Canan and Şenışık 1133

Table IV. Intragroup differences for the TBG: means, standard deviations, mean differences, and statistical signifi-
cance of treatment changes between time intervals
T1-T0 T2-T1 T2-T0

X 6 SD P X 6 SD P X 6 SD P
Maxillary superimposition measurements
z y
UR1-x 0.26 6 1.02 NS 0.88 6 0.75 0.62 6 0.73
UR1-y 0.28 6 0.62 NS 0.42 6 0.68 NS 0.14 6 0.48 NS
z
UR1-z 0.64 6 0.60 0.01 6 0.78 NS 0.63 6 0.87 *
z z
UL1-x 1.76 6 1.18 1.30 6 0.78 0.46 6 0.97 NS
UL1-y 0.23 6 0.78 NS 0.36 6 0.76 NS 0.13 6 0.66 NS
UL1-z 0.40 6 0.61 * 0.09 6 0.79 NS 0.49 6 0.77 *
y
UR3-x 0.70 6 1.09 * 0.56 6 0.70 0.14 6 1.10 NS
UR3-y 0.12 6 0.33 NS 0.23 6 0.66 NS 0.34 6 0.67 NS
UR3-z 0.25 6 0.59 NS 0.24 6 0.53 NS 0.10 6 0.63 NS
z y z
UL3-x 1.86 6 1.32 0.59 6 0.75 1.28 6 1.26
UL3-y 0.13 6 0.56 NS 0.62 6 1.62 NS 0.75 6 1.53 NS
UL3-z 0.66 6 1.15 NS 0.16 6 1.62 NS 0.51 6 1.78 NS
z z
UR4B-x 2.11 6 1.36 0.02 6 1.25 NS 2.13 6 1.27
UR4B-y 0.05 6 0.67 NS 0.15 6 0.63 NS 0.20 6 0.79 NS
UR4B-z 0.17 6 0.83 NS 0.01 6 0.67 NS 0.18 6 0.99 NS
z z
UR4P-x 1.93 6 1.43 0.12 6 1.33 NS 2.05 6 1.42
y
UR4P-y 0.34 6 0.65 NS 0.30 6 0.28 0.05 6 0.61 NS
UR4P-z 0.15 6 0.65 NS 0.39 6 0.84 NS 0.24 6 0.76 NS
z z
UL4B-x 2.83 6 0.98 0.34 6 0.56 * 3.16 6 1.04
UL4B-y 0.12 6 0.51 NS 0.22 6 0.53 NS 0.34 6 0.49 NS
UL4B-z 0.67 6 1.25 NS 0.13 6 1.43 NS 0.54 6 1.71 NS
z z
UL4P-x 2.81 6 0.93 0.13 6 0.59 NS 2.94 6 0.99
UL4P-y 0.39 6 0.57 * 0.22 6 0.78 NS 0.17 6 0.52 NS
UL4P-z 0.79 6 1.18 NS 0.28 6 1.79 NS 0.51 6 1.99 NS
z z
UR6MB-x 2.30 6 1.48 0.11 6 0.57 NS 2.19 6 1.24
UR6MB-y 0.33 6 0.57 * 0.10 6 0.46 NS 0.43 6 0.60 *
UR6MB-z 0.09 6 0.93 NS 0.24 6 0.56 NS 0.34 6 0.97 NS
z z
UR6MP-x 2.35 6 1.93 0.09 6 0.76 NS 2.26 6 1.67
y
UR6MP-y 0.03 6 0.77 NS 0.31 6 0.32 0.27 6 0.76 NS
UR6MP-z 0.08 6 1.06 NS 0.32 6 0.45 * 0.39 6 0.97 NS
z z
UL6MB-x 2.50 6 1.01 0.33 6 0.98 NS 2.83 6 1.03
y y
UL6MB-y 0.56 6 0.72 0.14 6 0.42 NS 0.70 6 0.77
UL6MB-z 0.69 6 1.27 NS 0.02 6 1.22 NS 0.67 6 1.70 NS
z z
UL6MP-x 2.59 6 1.07 0.15 6 0.75 NS 2.74 6 1.01
UL6MP-y 0.06 6 0.68 NS 0.31 6 0.50 NS 0.25 6 0.69 NS
UL6MP-z 0.81 6 1.38 NS 0.41 6 1.23 NS 0.40 6 1.48 NS
z
UR4-a 4.24 6 4.02 2.01 6 6.05 NS 2.23 6 6.51 NS
z y
UL4-a 5.44 6 4.49 0.76 6 7.85 NS 6.20 6 6.61
UR6-a 3.30 6 6.13 NS 1.46 6 4.16 NS 1.84 6 7.29 NS
z y
UL6-a 5.76 6 3.43 1.38 6 4.10 NS 4.38 6 4.86
Mandibular ınterdental arch width measurements
LL3-LR3 0.18 6 0.46 NS 0.14 6 0.60 NS 0.32 6 0.51 NS
LL4-LR4 0.02 6 0.54 NS 0.45 6 0.81 NS 0.43 6 1.07 NS
y z
LL6-LR6 0.37 6 0.42 0.34 6 0.54 * 0.71 6 0.56

T0, Pretreatment; T1, posttreatment; T2, postretention; X, mean; NS, not significant.
*P \0.05; yP \0.01; zP \0.001 (1-way analysis of variance for repeated measures value).

intergroup differences. This result agrees with the litera- of the teeth, and the methodologic differences in these
ture.6 In the intragroup differences for the TBG, the re- studies could be the reasons for these conflicting results.
sults for the canines agreed with a previous study26 but For the maxillary first premolars, expansion
disagreed with another.6 Retraction movement is was obtained in all groups. In the intergroup differences,
controversial in the literature for the BBG and the the amount of buccal movement of the right first premo-
HG.6,26 The design of appliances, the eruption timing lar (UR4B-x, UR4P-x) in the BBG was statistically lower

American Journal of Orthodontics and Dentofacial Orthopedics June 2017
Vol 151
Issue 6
1134 Canan and Şenışık

Table V. Intragroup differences for the BBG: means, standard deviations, mean differences, and statistical signifi-
cance level of treatment changes between time intervals
T1-T0 T2-T1 T2-T0

X 6 SD P X 6 SD P X 6 SD P
Maxillary superimposition measurements
y z
UR1-x 0.29 6 0.59 NS 0.78 6 0.88 1.07 6 0.98
UR1-y 0.06 6 0.92 NS 0.35 6 1.01 NS 0.40 6 0.60 NS
y y
UR1-z 0.30 6 0.36 0.29 6 0.64 NS 0.59 6 0.78
z z
UL1-x 2.01 6 1.24 1.11 6 0.93 0.89 6 1.24 *
UL1-y 0.20 6 0.77 NS 0.66 6 1.06 NS 0.46 6 0.70 NS
y y
UL1-z 0.65 6 0.80 0.02 6 0.56 NS 0.66 6 0.87
UR3-x 0.05 6 0.49 NS 0.42 6 0.90 NS 0.37 6 0.89 NS
UR3-y 0.13 6 0.47 NS 0.35 6 1.33 NS 0.22 6 1.21 NS
UR3-z 0.05 6 0.42 NS 0.37 6 0.91 NS 0.42 6 0.71
z y z
UL3-x 2.00 6 1.27 0.88 6 0.89 1.12 6 1.47
UL3-y 0.14 6 0.85 NS 0.20 6 1.14 NS 0.34 6 0.90 NS
y
UL3-z 0.77 6 0.94 0.47 6 0.95 NS 0.31 6 1.50 NS
y
UR4B-x 0.48 6 0.58 0.11 6 0.41 NS 0.36 6 0.55 *
UR4B-y 0.07 6 0.22 NS 0.26 6 0.40 NS 0.19 6 0.36 NS
UR4B-z 0.01 6 0.44 NS 0.31 6 0.52 NS 0.31 6 0.74 NS
y
UR4P-x 0.40 6 0.54 0.05 6 0.52 NS 0.51 6 0.76 *
UR4P-y 0.05 6 0.27 NS 0.16 6 0.32 NS 0.11 6 0.41 NS
z
UR4P-z 0.17 6 0.40 NS 0.41 6 0.38 0.24 6 0.53 NS
z z
UL4B-x 1.97 6 0.90 0.19 6 0.57 NS 1.78 6 1.01
UL4B-y 0.19 6 0.78 NS 0.21 6 0.83 NS 0.03 6 0.70 NS
y
UL4B-z 0.83 6 0.85 0.60 6 1.11 * 0.23 6 1.56 NS
z z
UL4P-x 2.15 6 1.09 0.19 6 0.58 NS 1.96 6 0.96
UL4P-y 0.26 6 0.46 NS 0.16 6 0.47 NS 0.10 6 0.56 NS
z
UL4P-z 0.83 6 0.74 0.48 6 0.90 * 0.35 6 1.31 NS
y
UR6MB-x 0.74 6 0.82 0.48 6 0.68 * 0.26 6 0.93 NS
UR6MB-y 0.10 6 0.52 NS 0.04 6 0.43 NS 0.06 6 0.35 NS
UR6MB-z 0.17 6 0.65 NS 0.29 6 0.56 NS 0.12 6 0.77 NS
y
UR6MP-x 0.67 6 0.75 0.40 6 0.72 * 0.26 6 1.14 NS
UR6MP-y 0.05 6 0.36 NS 0.17 6 0.35 NS 0.12 6 0.30 NS
UR6MP-z 0.25 6 0.54 NS 0.40 6 1.03 NS 0.15 6 1.16 NS
z z
UL6MB-x 1.92 6 1.17 0.40 6 0.93 NS 1.52 6 1.20
UL6MB-y 0.06 6 0.94 NS 0.09 6 0.89 NS 0.15 6 0.86 NS
z
UL6MB-z 1.06 6 0.90 0.57 6 1.60 NS 0.49 6 1.92 NS
z z
UL6MP-x 1.89 6 1.09 0.41 6 0.94 NS 1.48 6 1.22
UL6MP-y 0.42 6 1.72 NS 0.13 6 0.76 NS 0.29 6 1.26 NS
y
UL6MP-z 0.79 6 0.91 0.57 6 1.42 NS 0.22 6 1.62 NS
UR4-a 0.04 6 3.58 NS 0.88 6 3.78 NS 0.84 6 4.13 NS
UL4-a 1.41 6 3.40 NS 1.42 6 4.30 NS 0.01 6 4.49 NS
UR6-a 1.18 6 2.99 NS 1.73 6 3.52 NS 0.54 6 3.29 NS
z
UL6-a 0.37 6 4.19 NS 1.82 6 7.11 NS 1.45 6 6.94
Mandibular intermaxillary arch width measurements
LL3-LR3 0.10 6 0.29 NS 0.29 6 0.61 NS 0.19 6 0.74 NS
LL4-LR4 0.21 6 0.55 NS 0.16 6 0.72 NS 0.04 6 0.88 NS
y y
LL6-LR6 0.28 6 0.28 0.58 6 0.89 * 0.86 6 0.88

T0, Pretreatment; T1, posttreatment; T2, postretention; X, mean; NS, not significant.
*P \0.05; yP \0.01; zP \0.001 (1-way analysis of variance for repeated measures value).

than in the TBG at T1 and T2. Due to the design of the tooth-borne device maintained the obtained expansion
tooth-borne appliance in the TBG, the expansion effect width with tooth supports. During the retention period,
could be easily reflected onto the dentition via its tooth the maxillary base had a narrowing tendency with
support.4 Intragroup differences showed that, in the relapse, but the tooth supports of the device could not
TBG, the obtained expansion movement at T1 was move because of their rigidity. The lingual root move-
slightly continued at T2. In the retention period, the rigid ment of tooth supports combined with the narrowing

June 2017
Vol 151
Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Canan and Şenışık 1135

Table VI. Intragroup differences for the HG: means, standard deviations, mean differences, and statistical signifi-
cance level of treatment changes between time intervals
T1-T0 T2-T1 T2-T0

X 6 SD P X 6 SD P X 6 SD P
Maxillary superimposition measurements
y
UR1-x 0.56 6 1.60 NS 1.06 6 1.13 0.50 6 1.48 NS
UR1-y 0.33 6 1.17 NS 0.31 6 0.73 NS 0.02 6 1.36 NS
UR1-z 0.48 6 0.63 NS 0.23 6 0.69 NS 0.71 6 1.16 NS
y
UL1-x 1.57 6 1.86 1.17 6 1.85 * 0.40 6 1.61 NS
UL1-y 0.39 6 1.07 NS 0.31 6 0.74 NS 0.08 6 1.16 NS
UL1-z 0.31 6 1.65 NS 0.07 6 0.87 NS 0.37 6 1.61 NS
y
UR3-x 0.98 6 1.40 * 0.94 6 0.84 0.04 6 1.23 NS
y
UR3-y 0.17 6 0.67 NS 0.76 6 0.86 0.59 6 0.99 *
UR3-z 0.02 6 1.26 NS 0.27 6 0.67 NS 0.28 6 1.22 NS
UL3-x 1.56 6 1.86 * 0.43 6 1.83 NS 1.13 6 2.15 NS
y
UL3-y 0.13 6 1.20 NS 0.80 6 0.84 0.93 6 1.45 *
UL3-z 0.40 6 2.75 NS 0.01 6 1.46 NS 0.39 6 2.64 NS
y y
UR4B-x 1.22 6 1.20 0.27 6 0.87 NS 0.94 6 1.00
UR4B-y 0.09 6 0.52 NS 0.09 6 0.51 NS 0.18 6 0.78 NS
UR4B-z 0.38 6 0.83 NS 0.33 6 0.75 NS 0.71 6 1.01 NS
y y
UR4P-x 1.18 6 1.42 0.21 6 0.74 NS 0.98 6 1.18
UR4P-y 0.40 6 0.55 * 0.00 6 0.58 NS 0.40 6 0.74 NS
UR4P-z 0.20 6 1.23 NS 0.54 6 0.92 NS 0.74 6 1.42 NS
y
UL4B-x 1.51 6 1.95 0.00 6 1.54 NS 1.51 6 2.17 *
UL4B-y 0.26 6 0.70 NS 0.27 6 0.43 NS 0.53 6 0.84 NS
UL4B-z 0.65 6 2.32 NS 0.12 6 1.39 NS 0.77 6 2.32 NS
UL4P-x 1.50 6 2.09 NS 0.09 6 1.41 NS 1.40 6 2.24 NS
y y
UL4P-y 0.48 6 0.51 0.10 6 0.45 NS 0.58 6 0.67
UL4P-z 0.53 6 2.40 NS 0.22 6 1.10 NS 0.74 6 2.43 NS
z z
UR6MB-x 2.46 6 1.61 0.36 6 0.93 NS 2.82 6 1.50
UR6MB-y 0.33 6 0.85 NS 0.06 6 0.40 NS 0.39 6 1.08 NS
UR6MB-z 0.11 6 1.46 NS 0.02 6 0.94 NS 0.13 6 1.78 NS
z z
UR6MP-x 2.72 6 1.46 0.22 6 0.82 NS 2.95 6 1.41
UR6MP-y 0.37 6 0.91 NS 0.37 6 0.26 NS 0.00 6 0.94 NS
UR6MP-z 0.18 6 1.92 NS 0.15 6 1.08 NS 0.03 6 2.23 NS
z z
UL6MB-x 2.32 6 1.54 0.51 6 1.58 NS 2.83 6 1.69
UL6MB-y 0.17 6 0.57 NS 0.15 6 0.89 NS 0.32 6 0.91 NS
UL6MB-z 0.20 6 3.05 NS 0.08 6 1.50 NS 0.11 6 3.05 NS
z z
UL6MP-x 2.59 6 1.49 0.46 6 1.54 NS 3.05 6 1.86
UL6MP-y 0.27 6 0.49 NS 0.40 6 0.80 NS 0.13 6 0.76 NS
UL6MP-z 0.43 6 2.87 NS 0.26 6 1.37 NS 0.17 6 2.98 NS
UR4-a 3.08 6 4.87 * 0.91 6 2.02 NS 2.17 6 5.08 NS
UL4-a 2.13 6 5.47 NS 2.02 6 2.71 * 0.11 6 4.90 NS
z y
UR6-a 6.50 6 4.65 3.02 6 3.62 3.48 6 4.63 *
z
UL6-a 4.31 6 3.86 2.34 6 3.29 * 1.97 6 4.28 NS
Mandibular intermaxillary arch width measurements
LL3-LR3 0.12 6 0.27 NS 0.18 6 0.40 NS 0.31 6 0.52 NS
LL4-LR4 0.12 6 0.65 NS 0.31 6 0.48 NS 0.43 6 0.88 NS
y
LL6-LR6 0.31 6 0.42 * 0.54 6 1.03 NS 0.85 6 1.06

T0, Pretreatment; T1, posttreatment; T2, postretention; X, mean; NS, not significant.
*P \0.05; yP \0.01; zP \0.001 (1-way analysis of variance for repeated measures value).

of the apical base led to a slight buccal crown tipping. that were cemented to the bands of device did not
Buccal tipping of tooth supports increased the interpre- move with the triangular-shaped opening movement
molar width at the dental level and probably acted as if of apical base. Moreover, they rotated in the reverse di-
the expansion continued at T2. When the rotational rection during expansion. In the retention period, a
movements of the maxillary first premolars were as- slight relapse took place (Fig 7). These results were [F7-4/C]
sessed in the TBG, it was seen that the first premolars similar to those in the literature.26 In the BBG, the first

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Fig 6. Rotational movements in the transversal plane: milimetrical treatment changes according to
buccal and palatinal measurement points in x- and z-planes: A, TBG in T0-T1; B, TBG in T1-T2; C,
BBG in T0-T1; D, BBG in T1-T2; E, HG in T0-T1; F, HG in T1-T2.

premolars moved with the maxillary apical base during In this study, 22 patients in the total sample of 47 had
expansion (Fig 6). Lee et al26 reported mesial and intru- a unilateral crossbite on the right side, and 9 of them
sion movements, which were dissimilar to our results. In were in the BBG. It is likely that occlusion lock, which
the HG, the first premolars probably moved with the is caused by a unilateral crossbite, decreased the amount
maxillary apical base during expansion (Fig 6). Rota- of dental expansion movement, changed the expansion
tional expansion of the maxilla in the vertical dimension direction, and interrupted the expansion locally on the
and alveolar bending could be the reasons for the extru- right side in the dentoalveolar level in the BBG. Conflict-
sion movement of the palatinal cusp tip of maxillary first ing results have been reported in the literature.4,7
premolars. During RME, alveolar bending/tipping and Intragroup differences showed that, in the TBG,
dental tipping have been reported.27 These results agree expansion was maintained with a slight relapse in the
with the literature.5 retention period (Fig 6). In the vertical plane, the ob-
In our study, expansion was obtained for the maxil- tained extrusion, mesialization, and expansion move-
lary first molars (UR6MB-x, UR6MP-x, UL6MB-x, ment with the tooth-borne device resulted from dental
UL6MP-x) in all groups. The alterations in buccal move- tipping of the mesiopalatinal cusp tip of the maxillary
ment on the right side in the BBG were statistically sig- right first molar, agreeing with the literature.6,26 In the
nificant (P \0.01), but small (UR6MB-x, 0.80 mm; BBG, the first molars were accompanied by expansion
UR6MP-x, 0.67 mm). In the intergroup differences, the movement of the maxillary apical base. Similarly,
amount of expansion movement of the maxillary right distalization, expansion, and extrusion movements
first molar in the transversal plane in the BBG was statis- have been reported for the mesiopalatinal cusp tip of
tically lower than in the other groups (Table III). This dif- the first molar with bone-borne devices.6,26 In the HG,
ference increased during the retention period. The dental movements are shown in Figure 6. Unlike our re-
individual expansion capacity of the cranial sutures sults, asymmetric expansion5 and mesial movement6 of
may be the reason for asymmetric expansion.28 Further- the mesiopalatinal cusp tips of the first molars were re-
more, the design of the bone-borne device may not be ported. The use of different designs of bone-borne de-
sufficient to expand deeply locked posterior teeth caused vices, differences in regions of anchorage placement,
by a crossbite, because of the lack of tooth support. force distributions, activation protocols, and study

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Canan and Şenışık 1137

Fig 7. Angular changes between time intervals: A, TBG in T0-T1; B, TBG in T1-T2; C, BBG in T0-T1; D,
BBG in T1-T2; E, HG in T0-T1; F, HG in T1-T2.

methods might be the reasons for these conflicting all treatment groups resulted from the new occlusal con-
results. tacts that were obtained by expansion of the maxilla,
It was concluded that RME treatment, even using de- decreased lip and cheek pressures, and increased tongue
vices with different designs, causes alveolar bending27,29 pressure.35 These results agree with the literature.34,36
and dental tipping.5,14 Additionally, the tipping of the In this study, similar dentoalveolar treatment effects
tooth supports is asymmetrical,30 and different values were achieved in all groups, with the exception of a small
for the angular changes of each support in the maxilla degree of expansion movement on the right side in the
were determined.31,32 In this study, the effect of these BBG. Therefore, the null hypothesis was rejected. In
devices regarding angular measurements was future studies, using a bite-block in the mandible with
statistically similar and agreed with the literature.7 bone-borne appliances might be suggested to eliminate
When intragroup differences were assessed, dental probable occlusion lock from a crossbite. As well as be-
tipping was observed in the TBG and the HG (Fig 7). In ing associated with fewer complications clinically, the
the retention period, occlusal forces and cheek pressure hybrid hyrax device might be the favored option in
might cause slight uprighting. In the BBG, occlusal lock RME treatment.
could be the reason for uprighting of the maxillary right
first premolar during expansion. The reason for increased CONCLUSIONS
buccal tipping, observed after retention, could be the adap-
tation of the teeth to the apical base expansion. Our results 1. All 3 expanders in this study led to expansion with
are both supported5,7 and opposed33 in other studies. Dif- mild relapse.
ferences in treatment protocols, types of expansion device, 2. Intergroup differences showed that expansion at the
treatment periods, samples, study designs, and analysis dentoalveolar level on the right side was statistically
methods could be the reasons for these conflicting re- lower in the BBG.
sults5-7,33 in the literature as well as in our study. 3. Although outward tipping of the posterior teeth was
In the mandible, the treatment effects of the 3 devices altered by RME devices, there were no statistically
were similar regarding intercanine and intermolar width significant intergroup differences.
measurements. The results of the intercanine width mea- 4. Similar treatment effects and amounts of dental
surements agreed with some studies34 but conflicted expansion were observed in the mandibular first
with others.35 The increase in the intermolar width in molars in all groups.

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ACKNOWLEDGMENT 17. Chen G, Chen S, Zhang XY, Jiang RP, Liu Y, Shi FH, et al. Stable re-
gion for maxillary dental cast superimposition in adults, studied with
This study was funded by S€
uleyman Demirel Univer- the aid of stable miniscrews. Orthod Craniofac Res 2011;14:70-9.
18. Hazar S, Atag€ un Ç, Çelenk T. The effects of mini-implant sup-
sity Scientific Research Projects Foundation (Project
ported RPE: case report (poster presentation). Third World Implant
num: 3694-D2-13). Orthodontic Congress; Verona, Italy; 2011.
19. Hoggan BR, Sadowsky C. The use of palatal rugae for the assess-
ment of anteroposterior tooth movements. Am J Orthod Dentofa-
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