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THE EDWARD H. ANGLE SOCIETY OF THE EDWARD H. ANGLE SOCIETY OF ORTHODONTISTSORTHODONTISTS
Midwest ComponentMidwest Component
Annual MeetingAnnual Meeting Orlando, FloridaOrlando, FloridaJanuary 29January 29th _ th _ February 2February 2ndnd
20112011
CBCT EVALUATION OF CBCT EVALUATION OF SKELETAL, DENTAL, AND SKELETAL, DENTAL, AND VOLUMETRIC MAXILLARY VOLUMETRIC MAXILLARY
SINUS CHANGES ASSOCIATED SINUS CHANGES ASSOCIATED WITH TWO TYPES OF WITH TWO TYPES OF
MAXILLARY EXPANDERSMAXILLARY EXPANDERS
Valmy Pangrazio-Kulbersh, Valmy Pangrazio-Kulbersh, DDS, MSDDS, MS
CONTRIBUTORSCONTRIBUTORS
Dr. Paul WineDr. Paul Wine Dr. Richard KaczinskiDr. Richard Kaczinski Dr. Mariana HaugheyDr. Mariana Haughey
INTRODUCTIONINTRODUCTION
Rapid Maxillary Expanders1-7,11
Increase transverse width Increase transverse width of the maxillaof the maxilla
Correction of Cross bitesCorrection of Cross bites Addition of Arch LengthAddition of Arch Length Correction of Axial Correction of Axial
Inclinations of the Inclinations of the Posterior TeethPosterior Teeth
Broadening the SmileBroadening the Smile
INTRODUCTION
Preparation for Functional Jaw Orthopedics or Orthognathic Surgery
Mobilization of the Maxillary Sutural System Reduction in Nasal Resistance Improvement of Breathing
INTRODUCTIONINTRODUCTION
Side Effects of RPE1,12,13
Dental extrusion Lateral rotations of the maxillary segments Bite opening Dental tipping Alveolar bending Gingival recession
INTRODUCTION
Skeletal Effects Skeletal Effects 4,7,8
Sutural changes Widening of the nasal
cavity Subsequent soft tissue
changes Remodeling of the
maxillary sinus
INTRODUCTION
Widening of the nasal cavity
.
INTRODUCTION
.
INTRODUCTION
Previous ResearchPrevious Research8,18,19,20
Dental Casts Two dimensional postero-anterior cephalograms Occlusal radiographs High radiation CT scans-Linear measurements
INTRODUCTIONINTRODUCTION
Cone Beam Computed Tomography (CBCT) Evaluate craniofacial structures in three Evaluate craniofacial structures in three
dimensions with minimal distortiondimensions with minimal distortion Lower radiation doses than conventional CT Lower radiation doses than conventional CT
scansscans2222
INTRODUCTIONINTRODUCTION
The purpose of this study was to assess The purpose of this study was to assess three dimensionally, with the aid of ICat three dimensionally, with the aid of ICat technology, the maxillary skeletal, dental, technology, the maxillary skeletal, dental, soft tissue, and volumetric airway changes soft tissue, and volumetric airway changes associated with the banded versus the associated with the banded versus the bonded hyrax expanders. bonded hyrax expanders.
CBCT EVALUATION OF SKELETAL, DENTAL, AND CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH
TWO TYPES OF MAXILLARY EXPANDERSTWO TYPES OF MAXILLARY EXPANDERS
METHODS AND MATERIALSMETHODS AND MATERIALS
METHODS AND MATERIALSMETHODS AND MATERIALS
METHODS AND MATERIALSMETHODS AND MATERIALS
Inclusion CriteriaInclusion Criteria
Constricted maxillary arch with or without Constricted maxillary arch with or without cross-bitescross-bites
Full permanent dentitionFull permanent dentition
Absence of fluid accumulation in the Absence of fluid accumulation in the maxillary sinus maxillary sinus
METHODS AND MATERIALSMETHODS AND MATERIALS
Expansion ProtocolExpansion Protocol
1 turn per day for 4-6 weeks1 turn per day for 4-6 weeks 6-10mm of activation6-10mm of activation Expanders left in for 6 months as Expanders left in for 6 months as
retentionretention
T1: Pretreatment CBCT scanT1: Pretreatment CBCT scan T2: Immediately after expansion T2: Immediately after expansion
appliance removal (6 months post tx)appliance removal (6 months post tx)
METHODS AND MATERIALSMETHODS AND MATERIALS
Sagittal Plane Coronal plane Axial plane
METHODS AND MATERIALSMETHODS AND MATERIALS
Palatal Maxillary Width (mm) Palatal Maxillary Width (mm) PMW PMW
METHODS AND MATERIALSMETHODS AND MATERIALS
Buccal Maxillary Width (mm) Buccal Maxillary Width (mm) BMW BMW
METHODS AND MATERIALSMETHODS AND MATERIALS
Palatal CEJ to X (˚) PCEJ-X Palatal CEJ to X (˚) PCEJ-X
METHODS AND MATERIALSMETHODS AND MATERIALS
Buccal CEJ to X (˚) BCEJ-X Buccal CEJ to X (˚) BCEJ-X
METHODS AND MATERIALS
Buccal Cusp Tip to X (˚) BCusp-X Buccal Cusp Tip to X (˚) BCusp-X
METHODS AND MATERIALSMETHODS AND MATERIALS
Posterior Nasal Width (mm) Posterior Nasal Width (mm) PNW PNW
P
METHODS AND MATERIALSMETHODS AND MATERIALS
Nasal Floor Width (mm) NFW Nasal Floor Width (mm) NFW
METHODS AND MATERIALSMETHODS AND MATERIALS
Anterior Nasal Width (mm) Anterior Nasal Width (mm) NWH/NWL NWH/NWL
PNWNWHH
NWL
METHODS AND MATERIALSMETHODS AND MATERIALS
Maxillary Width (mm) MaxW Maxillary Width (mm) MaxW
METHODS AND MATERIALSMETHODS AND MATERIALS
Alar Width (mm) Alar Width (mm)
METHODS AND MATERIALSMETHODS AND MATERIALS
Maxillary Sinus Volume (mm³) Maxillary Sinus Volume (mm³) MSV MSV
METHODS AND METHODS AND MATERIALSMATERIALS
Posterior airway Volume Posterior airway Volume (mm³) PAV (mm³) PAV
METHODS AND MATERIALSMETHODS AND MATERIALS
Statistical AnalysisStatistical Analysis
To test for differences in how the two To test for differences in how the two samples change over time, mixed design samples change over time, mixed design analysis of variance (ANOVA) was done analysis of variance (ANOVA) was done with both between-subjects (bonded vs. with both between-subjects (bonded vs. banded) and within subjects (time) effectsbanded) and within subjects (time) effects
Post hoc t tests were used to determine Post hoc t tests were used to determine individual differencesindividual differences
CBCT EVALUATION OF SKELETAL, DENTAL, AND CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH
TWO TYPES OF MAXILLARY EXPANDERSTWO TYPES OF MAXILLARY EXPANDERS
RESULTSRESULTS
RESULTSRESULTS
Palatal Maxillary Width – Canine (mm)Palatal Maxillary Width – Canine (mm)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 16.36916.369 18.97718.977 2.6082.608 <.001<.001** within groupwithin group
BondedBonded 13.7813.78 15.9915.99 2.212.21 <.001<.001** within groupwithin group
Sig at startSig at start NSNS 0.3980.398 0.4230.423 Interaction effectsInteraction effects
*P≤.003P≤.003
RESULTSRESULTS Palatal Maxillary Width – 1Palatal Maxillary Width – 1stst Premolar (mm) Premolar (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 20.86920.869 23.3223.32 2.4512.451 <.001<.001** within groupwithin group
BondedBonded 17.6717.67 19.5719.57 1.91.9 <.001<.001** within groupwithin group
Sig at startSig at start NSNS 0.5510.551 0.2970.297 Interaction effectsInteraction effects*P≤.003
RESULTSRESULTS Palatal Maxillary Width – 2nd Premolar Palatal Maxillary Width – 2nd Premolar
(mm)(mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 24.16224.162 26.826.8 2.6382.638 <.001<.001** within groupwithin group
BondedBonded 20.520.5 22.3522.35 1.851.85 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.7880.788 0.1000.100 Interaction effectsInteraction effects*P≤.003P≤.003
RESULTSRESULTS Palatal Maxillary Width – 1Palatal Maxillary Width – 1stst Molar (mm) Molar (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 26.63826.63829.8329.83
883.23.2 <.001<.001** within groupwithin group
BondedBonded 22.0322.03 23.8123.81 1.781.78 <.001<.001** within groupwithin group
Sig at startSig at start ** 1.421.42 0.0020.002** Interaction effectsInteraction effects**P≤.003P≤.003
RESULTSRESULTS
RESULTSRESULTS Buccal Maxillary Width – Canine (mm)Buccal Maxillary Width – Canine (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 31.4531.4533.4233.42
331.9731.973 <.001<.001** within groupwithin group
BondedBonded 24.9824.98 26.6126.61 1.631.63 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.3430.343 0.4730.473 Interaction effectsInteraction effects*P≤.003P≤.003
RESULTSRESULTS Buccal Maxillary Width – 1Buccal Maxillary Width – 1stst Premolar (mm) Premolar (mm)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 38.08538.08541.1041.10
883.0233.023 <.001<.001** within groupwithin group
BondedBonded 30.6430.64 32.9432.94 2.32.3 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.7230.723 0.3140.314 Interaction effectsInteraction effects*P≤.003P≤.003
RESULTSRESULTS Buccal Maxillary Width – 2nd Premolar Buccal Maxillary Width – 2nd Premolar
(mm)(mm)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 44.13144.131 47.16247.162 3.0313.031 <.001<.001** within groupwithin group
BondedBonded 35.3235.32 37.7637.76 2.442.44 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.5910.591 0.3310.331 Interaction effectsInteraction effects
*P≤.003P≤.003
RESULTSRESULTS
Buccal Maxillary Width – 1Buccal Maxillary Width – 1stst Molar (mm) Molar (mm)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 50.9550.95 55.2855.28 4.334.33 <.001<.001** within groupwithin group
BondedBonded 40.3940.39 43.2543.25 2.862.86 <.001<.001** within groupwithin group
Sig at startSig at start ** 1.471.47 0.0180.018 Interaction effectsInteraction effects*P≤.003P≤.003
RESULTSRESULTS
RESULTSRESULTS Palatal CEJ Angulation (˚)Palatal CEJ Angulation (˚)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 25.2825.28 28.3628.36 3.093.09 <.001<.001** within groupwithin group
BondedBonded 25.2125.21 26.926.9 1.691.69 <.001<.001** within groupwithin group
Sig at startSig at start NSNS 1.401.40 0.0030.003** Interaction effectsInteraction effects**P≤.003P≤.003
RESULTSRESULTS Buccal CEJ Angulation (˚) Buccal CEJ Angulation (˚)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 41.0941.09 44.3044.30 3.223.22 <.001<.001** within groupwithin group
BondedBonded 40.9540.95 42.3142.31 1.361.36 <.001<.001** within groupwithin group
Sig at startSig at start NSNS 1.861.86 0.0010.001** Interaction effectsInteraction effects
**P≤.003P≤.003
RESULTSRESULTS Buccal Cusp Angulation (˚)
T1 T2 T1 to T2Significanc
eChange over time
BandedBanded 37.315 41.31 3.99 <.001* within group
BondedBonded 37.08 38.1 1.02 <.001* within group
Sig at startSig at start NS 2.97 <.001* Interaction effects*P≤.003P≤.003
RESULTSRESULTS Maxillary Width (mm)Maxillary Width (mm)
T1 T2 T1 to T2 Significance Change over time
BandedBanded 58.8658.86 61.4561.45 2.582.58 <.001<.001** within groupwithin group
BondedBonded 47.6847.68 49.6649.66 1.981.98 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.600.60 0.190.19 Interaction effectsInteraction effects
**P≤.003P≤.003
RESULTSRESULTS Posterior Nasal Width (mm)Posterior Nasal Width (mm)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 27.3627.36 29.6529.65 2.922.92 <.001<.001** within groupwithin group
BondedBonded 21.5321.53 23.1823.18 1.651.65 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.640.64 0.0720.072 Interaction effectsInteraction effects
**P≤.003P≤.003
RESULTSRESULTS Nasal Floor Width (mm)Nasal Floor Width (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 23.46223.462 25.6225.62 2.152.15 <.001<.001** within groupwithin group
BondedBonded 18.8418.84 20.8620.86 2.022.02 <.001<.001** within groupwithin group
Sig at startSig at start ** 0.130.13 0.7760.776 Interaction effectsInteraction effects
**P≤.003P≤.003
RESULTSRESULTS Anterior Nasal Width High (mm)Anterior Nasal Width High (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 22.8022.80 23.6123.61 0.810.81 0.140.14 within groupwithin group
BondedBonded 22.5922.59 24.0324.03 1.441.44 0.010.01** within groupwithin group
Sig at startSig at start NSNS -0.63-0.63 0.370.37 Interaction effectsInteraction effects
**P≤.05P≤.05
RESULTSRESULTS Anterior Nasal Width Low (mm)Anterior Nasal Width Low (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 16.2816.28 17.7117.71 1.431.43 0.020.02** within groupwithin group
BondedBonded 16.4816.48 17.8417.84 1.361.36 0.0080.008** within groupwithin group
Sig at startSig at start NSNS 0.070.07 0.920.92 Interaction effectsInteraction effects
*P≤.05P≤.05
RESULTSRESULTS Alar Width (mm)Alar Width (mm)
T1T1 T2T2 T1 to T2T1 to T2SignificancSignificanc
eeChange over time Change over time
BandedBanded 34.7234.72 36.0636.06 1.341.34 0.0060.006** within groupwithin group
BondedBonded 36.0036.00 37.2437.24 1.241.24 0.0480.048** within groupwithin group
Sig at startSig at start NSNS 0.100.10 0.880.88 Interaction effectsInteraction effects
**P≤.05P≤.05
RESULTSRESULTS Maxillary Sinus Volume (mm³)Maxillary Sinus Volume (mm³)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 21796.421796.4 24352.324352.3 2582.92582.9 <.001<.001** within groupwithin group
BondedBonded 27674.827674.8 29412.129412.1 1737.31737.3 <.001<.001** within groupwithin group
Sig at startSig at start NSNS 845.6845.6 NSNS Interaction effectsInteraction effects
*P≤.003P≤.003
RESULTSRESULTS Posterior Airway Volume (mm³)Posterior Airway Volume (mm³)
T1T1 T2T2 T1 to T2T1 to T2 SignificanceSignificance Change over time Change over time
BandedBanded 11858.911858.9 19277.919277.9 -7418.6-7418.6 NSNS within groupwithin group
BondedBonded 11518.711518.7 11423.611423.6 95.195.1 NSNS within groupwithin group
Sig at startSig at start NSNS 340,2340,2 NSNS Interaction effectsInteraction effects
**P≤.003P≤.003
0
5000
10000
15000
20000
25000
T1 T2
BandedBonded
CBCT EVALUATION OF SKELETAL, DENTAL, AND CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC MAXILLARY SINUS CHANGES VOLUMETRIC MAXILLARY SINUS CHANGES
ASSOCIATED WITH TWO TYPES OF MAXILLARY ASSOCIATED WITH TWO TYPES OF MAXILLARY EXPANDERSEXPANDERS
DISCUSSIONDISCUSSION
DISCUSSION
Dental TippingDental Tipping Multiple studies7,13,25 show that a decrease in sutural
opening can lead to dental tipping and alveolar bending
Garrett et al1 showed alveolar bending accounted for 13% of expansion at the 1st molar compared to 6% at the 1st premolar due a decrease in sutural opening.
Hicks28 showed that maxillary expansion produces close to 50% skeletal movement and 50% dental tipping.
DISCUSSION
Wertz26 verified the maxillary suture had a nonparallel opening during separation in a 3 to 1 ratio from anterior to posterior. Interlocking pyramidal process of the palatine bone Immobilization of the medial and lateral pterygoid
plates of the sphenoid bone
Age was the major contributing factor to prevention of sutural opening
DISCUSSION
The results obtained from this ICAT three dimensional study was similar to previous research that demonstrated that sutural opening in a triangular pattern with the wide base at the anterior portion of the maxilla
The current study showed significant differences of first molar tipping between banded and bonded expanders
More palatal alveolar bending was seen in the banded expander possibly due to dental tipping
Vanarsdall, Herberger TA: rapid palatal expansion:Long term stability and periodontal implication, unpublished thesis, Philadelphia 1987, university of Pennsylvania
•55 pacients .•8 - 13 years old. •Evaluated 8 to 10 years after expansion.•Expansion 10 a 10.5 mm in approx. 3 weeks.•Compared to 30 controls.
Showed that thinning of the buccal alveolar bone and increase in width of the lingual alveolar was more prominent with the Hass type of expander vs. the hyrax type.
Daniela Gamba Gaig, Jose fernando castanha Henriques, Guillerme janson, Marco roberto Freitas, Adriano Yacubian Fernandez. Periodontal effects of rapid maxillary expansion with tooth tissue borne appliance and tooth borne expanders a computed tomography evaluation. Am J Orthod dentofacial orthop 2006;129:749-758
Daniela Gamba Gaig, Jose fernando castanha Henriques, Guillerme janson, Marco roberto Freitas, Adriano Yacubian fernandez. Periodontal effects of rapid maxillary expansion with tooth tissue borne appliance and tooth borne expanders a computed tomography evaluation. Am J Orthod dentofacial orthop 2006;129:749-758
• expansores inducen pérdida de las paredes bucales de los dientes de anclaje especialmente en personas que las tienen finas.
• a nivel de premolares los expansores anclados solamente a dientes producen mas pérdida ósea que los expansores anclados a tejidos y dientes.
DISCUSSIONDISCUSSION
DISCUSSION
This difference may be due to the appliance design. bonded expander is cemented to all posterior
teeth with acrylic, dissipating forces
Banded expanders have bands on the first molars and premolars. These teeth must bear all the force exerted by the palatal expander.
DISCUSSION
Since it is more difficult to expand the posterior maxilla, it is not surprising that we see significant tipping of the first molar using a banded expander.
DISCUSSIONDISCUSSION Naso-maxillary ComplexNaso-maxillary Complex
Both appliances were equally successful in Both appliances were equally successful in increasing anterior/posterior nasal width, increasing anterior/posterior nasal width, nasal floor width, maxillary width, nasal soft nasal floor width, maxillary width, nasal soft tissue, and maxillary sinus volumetissue, and maxillary sinus volume
An increase in nasal width and maxillary An increase in nasal width and maxillary sinus volume can have significant effects on sinus volume can have significant effects on nasal respiration, nasal resistance, and soft nasal respiration, nasal resistance, and soft tissue nasal changestissue nasal changes4,10,294,10,29
DISCUSSION
Haas4 showed that by widening the maxilla, widening of the nose occurred as well as increased nasal respiration in chronic mouth breathers.
Berger et al.10 used photographic analysis to show soft tissue changes associated with maxillary expansion.
Garrett et al.1 showed a decrease in linear dimension of the maxillary sinus due to an increase width of the nasal cavity.
DISCUSSION
The current study suggests that skeletal width increases have a near 1:1 ratio with soft tissue increases after expansion
DISCUSSION
No previous studies have related anterior to posterior nasal bony changes which is now possible due to CBCT imaging. Expansion produces not only posterior, but anterior
nasal widening leading to subsequent soft tissue changes.
No current studies analyze three dimensional changes in the maxillary sinus and posterior airway after maxillary expansion The increase in maxillary sinus volume can possibly
improve nasal respiration, decrease nasal resistance, and increase airway reservoirs. Although there was an increase in posterior airway volume, the results were not significant possibly due to the large standard deviations observed.
DISCUSSION
In the future, CBCT imaging and volumetric software can be used to look at the entire naso-maxillary complex
CBCT EVALUATION OF SKELETAL, DENTAL, AND CBCT EVALUATION OF SKELETAL, DENTAL, AND VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH VOLUMETRIC AIRWAY CHANGES ASSOCIATED WITH
TWO TYPES OF MAXILLARY EXPANDERSTWO TYPES OF MAXILLARY EXPANDERS
CONCLUSIONSCONCLUSIONS
CONCLUSIONSCONCLUSIONS
CBCT can be used reliably to assess skeletal CBCT can be used reliably to assess skeletal and dental changes associated with rapid and dental changes associated with rapid palatal expansion.palatal expansion.
Both expanders increased the transverse Both expanders increased the transverse dimension of the skeletal and soft tissue dimension of the skeletal and soft tissue naso-maxillary complex equally. However, naso-maxillary complex equally. However, more dental tipping was observed with the more dental tipping was observed with the banded expander.banded expander.
Maxillary sinus volume increased between 6-Maxillary sinus volume increased between 6-11% after expansion but the posterior airway 11% after expansion but the posterior airway volume change was not significant.volume change was not significant.
WHERE DO WE GO FROM HERE?
INITIAL
14 años 2 meses
CVM 4
1/9/07 EXPANSION COMPLETED
1 vuelta por día
durante 1 mes 15 días
Expansion obtenida 12mm
10/2/07(5 MONTHS OF PROTRACTION)
Periodo de retención
5 meses
3/18/08
Tiempo de tratamiento
22 meses
Sean meadows 4/15/08
Un mes de posisionador
y ajuste oclusal
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