Skeletal and Dental Changes With Fixed Slow Maxillary Expansion Treatment.
Skeletal and Dental Changes With Fixed Slow Maxillary Expansion Treatment.
Skeletal and Dental Changes With Fixed Slow Maxillary Expansion Treatment.
M used for more than a century to correct Database of Systematic Reviews, American
maxillary transverse deficiency. Three College of Physicians Journal Club,
expansion treatment modalities are used Database of Abstracts of Reviews of Effects
today: rapid maxillary expansion (RME), and Cochrane Central Register of Con-
slow maxillary expansion (SME) and surgically assisted trolled Trials), EMBASE Excerpta Medica,
maxillary expansion. Since each treatment modality has Thomsen’s ISI Web of Sciences and
advantages and disadvantages, contro- LILACS. Eight articles met the initial
versy regarding their use exists. Practi- inclusion criteria. The authors found that a
Clinicians need significant deficiency in the studies was the
tioners select treatment appliances
to rely on based on their personal experiences and lack of a control group to factor out changes
their clinical on the patient’s age and malocclusion.1,2 in the dental arch and skeletal structures
experience, RME has been used extensively.3,4 associated with normal growth.
Conclusions and Clinical
experts’ Some limitations associated with it have
5 Implications. The authors found only a
opinions been reported, including bite opening, lower level of evidence. Therefore, they
6
relapse, microtrauma of the temporo-
and the limited could make no strong conclusions on dental
mandibular joint and the midpalatal
evidence suture,7,8 root resorption,7,8 tissue or skeletal changes that occurred after SME
concerning impingement and pain,9 and excessive treatment. Clinicians need to rely on their
slow maxillary tipping of anchorage teeth.9 clinical experience, experts’ opinions and
SME procedures produce less tissue the presented limited evidence concerning
expansion
SME treatments.
treatments. resistance around the circummaxillary Key Words. Slow maxillary expansion;
structures and, therefore, improve bone
formation in the intermaxillary suture, slow palatal expansion; treatment outcome;
which theoretically should eliminate or reduce the limi- systematic review.
tations of RME.2,10,11 For SME, only 10 to 20 newtons10,12
of force should be applied to the maxillary region,
depending on the age of the patient, compared with 15 to
50 N for RME.1,2,13 The most frequently used SME appli-
ances are minne-expanders3,8,10,14 and quad-helixes.15-17
Although the objective of both appliances is to achieve
physiological intermaxillary sutural expansion, We obtained articles for which the abstracts
the design and activation are different. Clinicians did not present enough relevant information to
should not assume that the skeletal and dental help us make a final decision regarding their
effects of the two appliances are equivalent, and inclusion. We also searched the reference lists of
they should consider the two treatment modali- the selected articles for additional relevant publi-
ties separately. cations that we may have missed in the database
We identified in the dental literature a system- searches.
atic review18 and two meta-analyses3,19 that All three of us obtained and independently
reported dental arch changes after RME, but we evaluated all of the articles from the selected
could not find any systematic reviews or meta- abstracts. Then we reached a consensus
analyses on the dental or skeletal changes asso- regarding which articles should be included in the
ciated with SME treatment. We conducted a systematic review. For articles in cases in which
study to evaluate skeletal and dental changes relevant data were not available in the publica-
after fixed appliance SME in orthodontic patients tion, we contacted the authors to obtain the
with constricted arches, using all available pub- required extra information.
lished scientific literature.
RESULTS
MATERIALS AND METHODS We observed that MEDLINE and PubMed had
We selected two literature search terms—“slow the greatest diversity of abstracts, but these
palatal expansion” and “slow maxillary expan- databases did not include all of the abstracts
sion”—with the help of a librarian who had expe- included in other databases (Table 1). All except
rience in searching health sciences one of the selected abstracts from
databases. We conducted computer- PubMed were included in MED-
ized searches using the following LINE and vice versa. All of the
All of the eight
databases: MEDLINE from 1966 to abstracts selected by Thomsen ISI’s
studies the authors
week three of July 2004; MEDLINE Web of Science, EMBASE and all
In-Process and Other Non-Indexed finally selected lacked EBM reviews—Cochrane DSR, ACP
Citations July 23rd, 2004; LILACS, control groups. Journal Club, DARE and CCRCT—
a literature database of Latin were included in MEDLINE. After
American and Caribbean health we reviewed the selected abstracts’
research, from 1982 to July 2004; reference lists, we included only one
PubMed from 1966 to week three of July 2004; more article20 that did not appear in any of the
EMBASE Excerpta Medica from 1988 to week 30 database’s searches (Table 1).
of 2004; Thomsen ISI’s Web of Science from 1975 All of the eight studies we finally selected had
to week three of July 2004; and all databases in specific methodological issues. Each lacked a con-
the Evidence Based Medicine (EMB) Reviews trol group,8,10,14-17,20,21 and four also did not have a
database—Cochrane Database of Systematic measurement error statement.10,15,16,21 A control
Reviews (DSR), American College of Physicians group is necessary to factor out normal growth
(ACP) Journal Club, Database of Abstracts of changes in the dental arch and craniofacial struc-
Reviews of Effects (DARE) and Cochrane Central tures. Measurement error statements are impor-
Register of Controlled Trials (CCRCT)—to the tant to evaluating the clinical significance of the
second quarter of 2004. reported findings. A summary of sample size,
We used the following inclusion criteria to methodology used and appliance used is pre-
select the appropriate articles: clinical trials, sented in Table 2 (page 197).
measurements made from dental casts or facial
radiographs, and no surgical or other simulta- DISCUSSION
neous treatment that could affect SME during the An evidence-based practice aims to provide the
evaluation period. best possible treatment based on sound evi-
We read the articles’ abstracts to determine the dence.22 There are different levels of evidence. The
eligibility of articles. Two of us (M.O.L., C.F.-M.) highest level is represented by randomized con-
independently completed the selection process. If trolled trials (level I), followed by nonrandomized
a discrepancy arose, a third researcher (P.W.M.) controlled trials or quasiexperimental studies
helped make the final decision. (level II). Both of these levels have two subcat-
TABLE 1
egories each: systematic reviews (if possible, the costs.25 Therefore, the application of evidence
meta-analysis) (subgroup A) and analyses of indi- into clinical practice has to be related to profes-
vidual studies (subgroup B). Nonexperimental sional expertise and the needs of the patient.
descriptive studies (observational, cohorts and Since SME involves an active expansion period
case reports) are level III, and expert opinions are of up to four months, clinicians cannot eliminate
the lowest level (level IV). Basic research (animal a patient’s normal growth as a confounding factor
and human physiology) can lead to inaccurate for the changes found. Because none of the
assumptions and does not represent direct evi- reviewed studies reported the use of a control
dence for clinical practice.23 group for comparison at the end of treatment,
In the absence of the highest level of evidence, clinicians should interpret carefully the clinical
clinicians have to make decisions based on lower significance of the findings. No strong conclusion
levels of evidence. Because lower levels of evi- can be made on dental or skeletal changes after
dence are prone to confounding and selection SME. When evaluating studies on SME treat-
bias,24 clinicians should carefully analyze the ments, we noticed some trends in the studies’
studies’ limitations. results. For example, the greatest changes
Scientific evidence alone does not dictate the reported were on the transverse plane, especially
selection of the treatment. When making health interdental widths, compared with those on the
care decisions, clinicians also should consider a sagittal and vertical planes.
combination of values from patients and from pro- The studies we selected that used quad-helix
fessionals (clinical, personal and social) that and minne-expander appliances reported active
determine if the intervention benefits are worth treatment times that varied from one to 3.6
TABLE 2
Akkaya and Five females No < 1 millimeter Model casts Minne- One-5.16
colleagues 8 and seven expander months
males (9.91- (bands)
13.75 years of
age; mean,
12.19 years)
Karaman 20 Four males No < 0.9°, < 0.9 mm PA cephalometric Nitanium 3.6 months
and 12 in cephalometric radiographs, lateral maxillary
females radiographs, cephalometric expander
(mean, 13.8 < 0.5 mm in radiographs and
years of age) model casts model casts
months.8,10,14-17,20,21 These studies reported dental It appears that approximately 1 millimeter per
and skeletal changes through the use of dental week is the maximum rate at which the tissue of
casts and cephalometric radiographs. Both of the midpalatal suture can adapt so that tearing
Akkaya and colleagues’ studies8,14 reported the and hemorrhaging are minimized compared with
same sample and expansion protocol, differing rapid expansion protocols.10 The overall result of
only on the auxiliary examination used for mea- rapid versus slow expansion is similar; however,
suring the changes; thus, clinicians could combine with slower expansion, a more physiological
their results and consider them one whole study. sutural response should be obtained.12
and skeletal changes during that time. When the Eur J Orthod 1994;16(6):479-90.
8. Akkaya S, Lorenzon S, Ucem TT. Comparison of dental arch and
reported treatment changes were small—with arch perimeter changes between bonded rapid and slow maxillary
significant standard deviations and measurement expansion procedures. Eur J Orthod 1998;20(3):255-61.
9. Capelozza Filho L, Cardoso Neto J, da Silva Filho OG, Ursi WJ.
errors—the importance of the use of a control Non-surgically assisted rapid maxillary expansion in adults. Int J
group increased. Thus, we recommend that fur- Adult Orthodon Orthognath Surg 1996;11(1):57-66; discussion 67-70.
10. Hicks EP. Slow maxillary expansion: a clinical study of the
ther research on the effects of SME treatments on skeletal versus dental response to low-magnitude force. Am J Orthod
patients should include a control group. 1978;73(2):121-41.
11. Mew J. Relapse following maxillary expansion: a study of twenty-
Since the research studies on SME treatment five consecutive cases. Am J Orthod 1983;83(1):56-61.
we reviewed failed to give a higher level of scien- 12. Proffit WR, Fields HW. Contemporary orthodontics. 3rd ed. St.
Louis: Mosby; 2000:508-11.
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sions regarding dental or skeletal changes after therapy during the transitional dentition. ASDC J Dent Child
1993;60(4):408-13.
SME. We recommend that clinicians use the 14. Akkaya S, Lorenzon S, Ucem TT. A comparison of sagittal and
results of the studies we reviewed with caution. vertical effects between bonded rapid and slow maxillary expansion
procedures. Eur J Orthod 1999;21(2):175-80.
As in any clinical environment, clinicians should 15. Malagola C, Caligiuri FM, Barbato E, Pachi F. Slow expansion of
rely on their clinical experiences, the opinion of the upper jaw using Quad-Helix (in Italian). Mondo Ortod 1988;13(4):
119-25.
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Dr. Lagravère is a doctoral student, Orthodontic Graduate Program, 17. Sandikcioglu M, Hazar S. Skeletal and dental changes after max-
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tistry, Room 4051A, Dentistry/Pharmacy Centre, University of Alberta, ances on dentofacial structures. Angle Orthod 2002;72(4):344-54.
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