Journal Club: Dr. Balarama Krishna Academic JR Department of Dentistry AIIMS, Bhubaneswar

Journal Club
Dr. Balarama krishna

Academic JR
Department of Dentistry
AIIMS,Bhubaneswar
Title Integration of digital maxillary dental casts with 3D facial images
in orthodontic patients: A three-dimensional validation study.
Authors Zhuoxing Xiao; Zijin Liu; Yan Gu
DOI No. 10.2319/071619-473.1
Origin Department of Orthodontics, National Engineering
Laboratory for Digital and Material Technology of Stomatology,
Beijing Key Laboratory of Digital Stomatology, Peking
University School and Hospital of Stomatology, Beijing, China
Type of the article Original article
Journal name The Angle Orthodontist
Type of study Retrospective
How to cite ? Xiao Z, Liu Z, Gu Y. Integration of digital maxillary dental casts
with 3D facial images in orthodontic patients: A three-
dimensional validation study. The Angle Orthodontist. 2020
May;90(3):397-404.
Publisher E H Angle Education and Research Foundation

Editor Steven J. Lindauer
Frequency Bi-Monthly
Impact factor 1.225 (2014)
• Rapid maxillary expansion (RME) is used in the orthodontic to treat
• Patients with transverse maxillary deficiency
• Dental crowding
• Mandibular functional shift
• Transverse expansion is achieved through skeletal expansion, ie,

opening of midpalatal sutures with separation of maxillary halves and
dentoalveolar expansion
• Tooth borne expansion appliances produce varying amounts of dental
and skeletal expansion.
• Skeletal expansion is about half or less of the total amount of

resulting expansion in adolescent patients.
• As the midpalatal sutures undergo maturation and fusion from

childhood to late adolescence and adulthood, the amount of skeletal
expansion with conventional RME and its longterm stability
decreases.
• Failure of RME to open the suture is associated with unwanted
dentoalveolar side effects
• Pain
• Severe buccal tipping
• Extrusion of teeth
• Gingival recession
• Buccal cortex fenestration
• Root resorption
• Bone-borne RME (or miniscrew assisted RME) was recently proposed
to minimize the unwanted dentoalveolar effects of RME and produce
greater skeletal changes.
• In the bone-borne RME, palatal miniscrews are used as anchorage to

transfer the expansion force directly to the skeletal structures.
• Lin et al. (2015) greater skeletal expansion, less buccal tipping of first
molars, and less buccal dehiscence following the bone-borne RME
than expansion with tooth-borne RME using a hyrax appliance.
• Garrett et al.(2008) showed that the average increase in nasal width

following tooth-borne expansion with a hyrax was only 37% of the
total appliance expansion
• Heavy forces generated by expanders could impact the craniofacial
structures beyond the midpalatal suture.
• Following RME, high levels of stress were observed in surrounding
structures, such as
• Zygomaticomaxillary
• Zygomaticotemporal
• Frontomaxillary sutures
• Frontal process of the maxilla
• External wall of the orbits
• Widening of nasal apertures, separation of the nasal floor, and displacement
of the lateral nasal walls were also reported to be associated with sensation
of pressure in the maxillary, nasal, or orbital areas.
Aim and objective
• To measure and compare the changes in airway volume of the nasal
cavity, maxillary sinuses, and pharynx after use of bone- or tooth-
borne expansion appliances.
• Secondary purpose : to evaluate the dentoskeletal effects of each

expansion modality
Materials and Methods
• The study was approved by the Institutional Review Board of Indiana
University–Purdue University
• This retrospective study included adolescent subjects who completed
their orthodontic treatment at the same orthodontic clinic (University
of Alberta, Edmonton, Canada).
• The inclusion criteria :
• 11 and 15 years of age
• No history of orthodontic treatment, temporomandibular joint disorder,

adenoidectomy or tonsillectomy, periodontal diseases, systemic diseases,
craniofacial anomalies, and no active caries.
• All subjects had a bilateral maxillary crossbite and received bone-borne RME
or tooth-borne RME as part of their comprehensive orthodontic treatment.
• The randomization of assigning the treatment group resulted in the two

groups having no significant differences in their initial conditions
• The tooth-borne expander design included a hyrax appliance with
bands on the permanent first molars and first premolars. If
permanent first premolars were not erupted, bands were placed on
deciduous first molars.
• In the bone-borne RME group, two miniscrews (length: 12 mm;
diameter: 1.5 mm; Straumann GBR System, Andover, MA) were
placed in the palate between the permanent first molars and second
premolar and were connected with a jackscrew (Palex II Extra-Mini
Expander, Summit Orthodontic Services, Munroe Falls, OH; Figure 1B)
Activation
• The activation rate was same in the tooth-borne expander and bone-
borne expander groups.
• Two turns per day i.e. 0.5mm/day
• The expansion continued until the mesiopalatal cusps of the maxillary
first permanent molars were in contact with the buccal cusps of
mandibular first permanent molars.
• All subjects had two cone beam computed tomography (CBCT) scans
acquired, one before the expansion (T1) and one after a 3-month
retention period (T2). All patients were scanned with the iCAT CBCT
Unit (Imaging Sciences International, Hartfield.
• Using same setting protocol: 0.3 voxel, 8.9 seconds, large field of view
at 120 kV and 20 mA.
Sample Size
• 20 subjects were in the bone-borne and 20 subjects in the tooth-
borne expansion groups.
• Three subjects (one in the bone-borne and two in the tooth-borne

group) were excluded due to motion artifact in the CBCT images.
• In addition, one subject was excluded from the bone-borne group

since the subject showed excessive opacification of the maxillary
sinuses and nasal cavity in the T2 CBCT image.
• 18 subjects (10 females: eight males; average age: 14.46 ± 1.3 years)
who received tooth-borne RME
• 18 subjects (12 females: six males; average age: 14.76 ± 1.4 years)
who received bone-borne RME were included in the final analyses
• Dolphin Imaging Software, version 11.0 (Dolphin Imaging,
Chatsworth, CA), was used for image analyses.
• Analysis was performed using the same computer monitor and light
settings (24-in. monitor; Dell, Round Rock, TX; 1920 3 1200 pixels).
• The investigators (G.K. and A.G.) traced and analyzed 10 randomly
selected study images independently to determine the inter-rater
reliability.
• In addition, the primary investigator (G.K.) repeated the same
measures after 2 weeks to determine the intra-examiner reliability.
• A minimum intraclass correlation coefficient of 0.8 was necessary
before the analyses of the remaining CBCT images were permitted
• Three-dimensional (3D) airway volumetric and soft-tissue landmarks
were previously established by Smith and colleagues (2012)
Boundaries of nasal cavity. (A) Boundaries of airway spaces. (A) Nasopharynx. (B)
Frontal view. (B) Sagittal Oropharynx. (C) Right maxillary sinus.
Skeletal expansion measured at the level of maxillary first molars: (1) External maxillary width, (2)
Palatal width. (B) Intermolar width measured at the level of: (3) Palatal root apices, (4) Central fossae of
maxillary first molars
C )Buccal inclination of the maxillary left first molar
Statistical Analysis
• Sample size of 20 subjects per treatment group
• Significance level of 0.05
• Power of the study 80%
• Correlation coefficient of 0.58
• Analysis of variance (ANOVA) was used to test for differences
between methods for pre treatment and post treatment
• Paired t-tests were also used to test for significant changes pre- and
post- intervention within each method
• 5% significance level was used for all the tests
• The intra-rater and inter-rater reliability for all the measurements was
high, with intraclass correlation coefficients above 0.80
Pre- and Post-expansion Comparison Within
Each RME Group
Tooth borne appliance

Pre- and Post-expansion Comparison Between RME Groups
Discussion
• Buccal tipping of molars was observed only in the tooth-borne
expansion group.
• Lin et al. (2015) compared dentoalveolar and skeletal effects of a

bone-borne expander to those of a tooth borne expander in a group
of adolescent patients. They found more buccal tipping of maxillary
molars in the tooth-borne group.
• Lagravere et al.(2010) found no significant difference in dental and
skeletal expansion at the maxillary first molar between the
adolescents who received tooth and bone-borne expansion.
• The change in the buccal inclination of the right maxillary first molar
was significantly higher after tooth-borne RME than bone borne RME
but the difference in the buccal inclination of the left maxillary first
molar was not significantly different between the two.
• Kim et al.(2018) evaluated airway volume changes after miniscrew-
assisted rapid maxillary expansion in young adults using CBCT images.
• They demonstrated that the volume, as well as the anterior and

middle cross-sectional area of nasal cavity, increased significantly
after expansion.
• The increase was retained at a 1-year follow-up visit.
• However, observed changes in nasopharynx volume were not

significant.
• The disagreement could be due to differences in the definition of
nasopharynx between the two studies.
• The space, which was defined separately as the oropharynx in the

present study, was included as part of the nasopharynx in Kim’s study.
• Bazargani et al.(2018) compared the effects of tooth-bone-borne
(hybrid) and tooth-borne RMEs on nasal airflow and resistance using
rhinomanometry examination after decongestion.
• They concluded that tooth-bone-borne RME resulted in higher nasal

airflow and lower nasal resistance than tooth-borne RME in children.
• Significantly larger increase in buccal inclination of the maxillary right

first molar after toothborne expansion.
• Vale F et al.(2017) evaluated the effect of tooth-borne RME on
treatment of patients with obstructive sleep apnea.
• They showed that RME was an effective tool for normalization of

apnea-hypopnea index (AHI) and improvement of obstructive sleep
apnea syndrome in children.
• The present study demonstrated that both bone- and tooth-borne

expanders appeared to be viable options for increasing the volume of
the nasal cavity, as well as the nasopharynx.
• Future studies are warranted to compare the impact of the two
expansion modalities on respiratory pattern and signs and symptoms
of children with obstructive sleep apnea syndrome.
CONCLUSIONS
• Both tooth- and bone-borne rapid maxillary expanders significantly
increased the volume of the nasal cavity and nasopharynx, as well as
maxillary dental and skeletal width.
• Only the tooth-borne expander group showed significant buccal
tipping of maxillary molars.
• No statistically significant difference was observed in nasal cavity or
nasopharynx volume changes between the two expansion groups.
Thank you!

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Journal Club

Dr. Balarama krishna

Publisher E H Angle Education and Research Foundation

• Transverse expansion is achieved through skeletal expansion, ie,

• Skeletal expansion is about half or less of the total amount of

• As the midpalatal sutures undergo maturation and fusion from

• In the bone-borne RME, palatal miniscrews are used as anchorage to

• Garrett et al.(2008) showed that the average increase in nasal width

• Secondary purpose : to evaluate the dentoskeletal effects of each

• No history of orthodontic treatment, temporomandibular joint disorder,

• The randomization of assigning the treatment group resulted in the two

• Three subjects (one in the bone-borne and two in the tooth-borne

• In addition, one subject was excluded from the bone-borne group

• 5% significance level was used for all the tests

Tooth borne appliance

• Lin et al. (2015) compared dentoalveolar and skeletal effects of a

• They demonstrated that the volume, as well as the anterior and

• The increase was retained at a 1-year follow-up visit.

• However, observed changes in nasopharynx volume were not

• The space, which was defined separately as the oropharynx in the

• They concluded that tooth-bone-borne RME resulted in higher nasal

• Significantly larger increase in buccal inclination of the maxillary right

• They showed that RME was an effective tool for normalization of

• The present study demonstrated that both bone- and tooth-borne

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