Cbc teval of exp -compressed

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


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


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


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



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


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)


Sagittal Plane Coronal plane Axial plane


Palatal Maxillary Width (mm) Palatal Maxillary Width (mm) PMW PMW


Buccal Maxillary Width (mm) Buccal Maxillary Width (mm) BMW BMW


Palatal CEJ to X (˚) PCEJ-X Palatal CEJ to X (˚) PCEJ-X


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


Posterior Nasal Width (mm) Posterior Nasal Width (mm) PNW PNW

P


Nasal Floor Width (mm) NFW Nasal Floor Width (mm) NFW


Anterior Nasal Width (mm) Anterior Nasal Width (mm) NWH/NWL NWH/NWL

PNWNWHH

NWL


Maxillary Width (mm) MaxW Maxillary Width (mm) MaxW


Alar Width (mm) Alar Width (mm)


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


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



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



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)





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)



BandedBanded 26.63826.63829.8329.83

883.23.2 <.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)



BandedBanded 31.4531.4533.4233.42




RESULTSRESULTS Buccal Maxillary Width – 1Buccal Maxillary Width – 1stst Premolar (mm) Premolar (mm)


BandedBanded 38.08538.08541.1041.10




RESULTSRESULTS Buccal Maxillary Width – 2nd Premolar Buccal Maxillary Width – 2nd Premolar

(mm)(mm)




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)





RESULTSRESULTS

RESULTSRESULTS Palatal CEJ Angulation (˚)Palatal CEJ Angulation (˚)





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 (˚)




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




**P≤.003P≤.003

RESULTSRESULTS Posterior Nasal Width (mm)Posterior Nasal Width (mm)





**P≤.003P≤.003

RESULTSRESULTS Nasal Floor Width (mm)Nasal Floor Width (mm)






**P≤.003P≤.003

RESULTSRESULTS Anterior Nasal Width High (mm)Anterior Nasal Width High (mm)



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)



BandedBanded 16.2816.28 17.7117.71 1.431.43 0.020.02** within groupwithin group



*P≤.05P≤.05

RESULTSRESULTS Alar Width (mm)Alar Width (mm)



BandedBanded 34.7234.72 36.0636.06 1.341.34 0.0060.006** within groupwithin group



**P≤.05P≤.05

RESULTSRESULTS Maxillary Sinus Volume (mm³)Maxillary Sinus Volume (mm³)




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)


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



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

Business

Cbc teval of exp -compressed