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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 173-179

The evaluation of the effects of rapid palatal expansion on nasomaxillary complex in patients with complete unilateral and bilateral cleft lip and palate


Department of Orthodontics, Faculty of Dentistry, Ege University, Izmir, Turkey

Date of Web Publication21-Nov-2017

Correspondence Address:
Ege Dogan
Department of Orthodontics, Faculty of Dentistry, Ege University, Bornova, Izmir
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_28_17

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  Abstract 

Aim: The aim is to evaluate the effects of rapid palatal expansion (RPE) in children with complete unilateral and bilateral cleft lip and palate (UCCLP/BCCLP), compared with noncleft patients. Materials and Methods: This study includes 45 patients aged between 8 and 11 years old (15 patients with UCCLP; mean age: 9 years 2 months, 15 patients with BC-CLP; mean age: 9 years, 15 patients with noncleft; mean age: 9 years 1 month), in Ege University, Department of Orthodontics. RPE was applied before secondary alveolar grafting. Posteroanterior cephalograms were taken before and after expansion. One-way analysis of variance was used to analyze the differences among the groups, whereas the paired t-test was used to evaluate the changes in each group. Results: In all groups, RPE causes a significant increase of the internasal dimension and maxillary width (Ln-Ln', Mx-Mx'). In the cleft groups, especially in the bilateral CLP group, the nasal width (Ln-Ln') and maxillary width (Mx-Mx') show a statistically significant increase according to the control group (P < 0.001). Furthermore, the unilateral CLP group shows an increase according to the control group (P < 0.001).(Um-Um') and (Lm-Lm') show a statistically significant increase all in three groups compared before the treatment (P < 0.001).(Um-Um') show the most increase in bilateral CLP group (P < 0.001). In the bilateral CLP group, (Zyg-Zyg'), (Cdl-Cdl'), (Go-Go') show a statistically significant increase (P < 0.001). The control and unilateral CLP group also show an increase, but the unilateral CLP group is not found statistically significant. Conclusion: When the facial morphologies were evaluated after RPE, the facial width measurements of the bilateral CLP patients showed a greater increase than the unilateral CLP and control group. Nasal width measurements were wider in cleft groups compared to the control group contributing to a widened airway, which may have an effect on breathing and speaking in cleft patients. More studies are needed.

Keywords: Cleft lip and palate, nasomaxillary complex, rapid palatal expansion


How to cite this article:
Dogan E, Dogan S. The evaluation of the effects of rapid palatal expansion on nasomaxillary complex in patients with complete unilateral and bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:173-9

How to cite this URL:
Dogan E, Dogan S. The evaluation of the effects of rapid palatal expansion on nasomaxillary complex in patients with complete unilateral and bilateral cleft lip and palate. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:173-9. Available from: https://www.jclpca.org/text.asp?2017/4/3/173/218868


  Introduction Top


Rapid maxillary expansion (RME) or rapid palatal expansion (RPE), is a method, which applies reciprocal forces on posterior maxillary teeth laterally. In addition, RPE causes the medial palatinal suture to open wider. As a result, the bones connected to maxilla moves with the exception of the sphenoid bone. The midpalatal suture opening shows a triangular shape; vertex toward the nasal cavity and base toward to the anterior nasal spine[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13] Angell EC,[14] found RME in 1860. Angell suggested that there is an aperture in the midpalatal suture, but he could not prove it because radiography did not exist. In 1909, Landsberger.[15] proved this information radiographically. Radiographic evidence from patients without cleft shows widening of the dental arch and orthopedic disjunction of the maxilla causing significant effects on nasal cavity.

Maxillary deficiency is seen on patients with cleft lip and palate (CLP), because of lip and palate repair are performed at early stages of growth, causing anteroposterior, vertical, and transversal maxillary deficiencies. This causes skeletal anterior and posterior crossbites with the depression in the midface. These deficiencies also cause changes in the nasomaxillary area transversally. The maxillary expansion is mostly needed in CLP patients because of this excessively narrow maxilla.[1],[2],[3],[4],[5],[6],[7] As a result of the anatomical structure of the maxilla, the effects of RPE differ in cleft patients. It increases the maxillary dental arch, treats the crossbite, aligns the maxillary segments, increases the alveolar cleft width and creates room for bone graft placement[1],[2],[3],[4],[6],[7],[13] In literature, size and shape measurement studies are so limited in cleft patients.[1],[9],[16]

The aim of this study is to evaluate the effects of RPE on nasomaxillary complex in children with complete unilateral (UCCLP) and bilateral (BCCLP) CLP, compared with noncleft patients.


  Materials and Methods Top


This study includes totally 45 patients aged between 8 and 11. The control group consisted of 15 noncleft Angle Class I patients (7 boys, 8 girls: Mean age: 9 years 1 month) with anterior and posterior crossbites. The experimental group included 15 UCCLP (8 boys, 7 girls, mean age: 9 years 2 months) and 15 BCCLP patients (7 boys, 8 girls, mean age: 9 years).

The project was approved by the institutional ethics committee. Parents were duly briefed by the doctor about the procedures involved in the study and requested to sign an informed consent form for treatment.

The inclusion criteria for cleft groups were: (1) both sexes, (2) lip and palatal repair in early childhood, (3) mixed dentition or early permanent dentition with no missing posterior teeth, (4) maxillary constriction and need for maxillary expansion before the secondary alveolar bone graft. The inclusion criteria for the noncleft control group were: (1) both sexes, (2) Angle Class I occlusion with anterior and/or posterior crossbites, (3) mixed dentition or early permanent dentition with no missing posterior teeth, (4) maxillary constriction and need for maxillary expansion. The exclusion criteria for all groups were: (1) associated syndromes, (2) craniofacial anomalies, (3) poor oral hygiene and (4) respiratory or allergic symptoms.

All patients had already undergone primary plastic surgeries in the first infancy. In the cleft groups, the lip operation was done on the 3rd month, the palate operation was done on the 12th month both on UCCLP and BCCLP patients. These CLP surgeries were done by many different surgeons many consisting of varying surgical techniques.

In both cleft groups, RPE was done before secondary alveolar grafting. All patients had posteroanterior cephalograms before and after the expansion, subsequently evaluated statistically.

The Hyrax expander, a tooth-borne, acrylic bonded appliance was used in patients for RPE in this study [Figure 1]. This expander has a good stability, and it is easy to use.
Figure 1: Appliance used for rapid maxillary expansion

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The expander screw (Forestadent 12 mm Golden Spindle Palatal Expander) was activated until palatal cusps of the maxillary first molars had contact with the buccal cusps of the mandibular first molars. All patients had the same activation protocol of one complete turn in the morning and one complete turn in the evening; contingent on the severity of maxillary transverse deficiency. Each complete turn of the expansion screw corresponded to an opening of approximately 0.8 mm. At the end of the active expansion phase, the expander was kept in the mouth for at least 3 months.

The reference points and lines used in the analysis of posteroanterior radiographs are shown in [Figure 2] and [Figure 3].
Figure 2: (Zyg-Zyg'): Cleft and noncleft points on the lateral border of the center on the zygomatic arch. (Cdl-Cdl'): Most upper lateral points both on cleft and noncelft sides. (Ln-Ln'): Widest and most out point of the nasal cavity both on cleft and noncleft sides. (Mx-Mx'): Deepest points on the lateral section of the maxillary concavity both on cleft and noncleft sides. (Go-Go'): Deepest points on the antegonial notch both on cleft and noncleft sides. (Um-Um'): Most lateral point of the upper first molar.(Lm-Lm'): Most lateral point of the lower first molar

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Figure 3: (Zyg-Zyg') (mm): Width between the zygomatical points. (Cdl-Cdl') (mm): Width between the condylar points.(Ln-Ln') (mm): Width between the nasal points. (Mx-Mx') (mm): Width between the maxillary points.(Go-Go') (mm): Width between the antegonial points.(Um-Um') (mm): Width between the upper first molars. (Lm-Lm') (mm): Width between the lower first molars

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Statistical analysis

One-way analysis of variance was used to analyze differences among the groups. Intragroup treatment changes were evaluated with paired t-tests. Intergroup treatment changes were compared with t tests. The results were considered statistically significant at P < 0.05.


  Results Top


The distribution of the patients; mean age at the beginning of treatment, standard deviation, number, and gender of the subjects are shown in [Table 1]. The random errors varied from 0.17 to 0.98 mm for the linear measurements, no significant systematic error was found. [Table 2] shows the intragroup treatment changes in the experimental and control groups. In all groups, maxillary expansion produced significant increases in the internasal dimension and maxillary transverse measurements [Table 2]. RPE causes a significant increase of the internasal dimension and maxillary width (Ln-Ln', Mx-Mx') in all groups.
Table 1: The distribution of the patients (mean age at the beginning of treatment, standard deviation, number, and gender of the subjects)

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Table 2

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Table 3: Intergroup treatment changes

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[Table 3] shows the intergroup treatment changes. In CLP group, especially the BCCLP group, the nasal width (Ln-Ln') and maxillary width (Mx-Mx') measurements showed statistically significant increases according to the control group (P < 0.001). In addition, UCCLP group shows an increase in (Ln-Ln') and (Mx-Mx') according to the control group (P < 0.001). Um-Um', Lm-Lm' measurements showed statistically significant increases in three groups compared to pretreatment (P < 0.001). Um-Um' measurement shows the most increase in BCCLP group (P < 0.001). In BCCLP group, Zyg-Zyg', Cdl-Cdl', Go-Go' measurements show a statistically significant increase (P < 0.001). The control and UCCLP group also show an increase but is not found statistically significant [Table 3].


  Discussion Top


One of the most seen anomalies with the cleft patients is posterior crossbite and maxillary arch collapse. The researchers stated that frequencies of crossbite in children with UCLP in the deciduous, mixed, and permanent dentitions are very high. The operated lip and palate influence maxillary growth in a negative way, they cause anteroposterior, vertical, and transversal maxillary deficiencies.[1],[2],[6],[7],[13],[16],[17],[18],[19] When evaluating the Oslo CLP growth file, Semb,[20] found that approximately 25% of the patients had crossbites. Ayub et al.[21] examined the dentoalveolar effects of RME in 25 patients with UCCLP and posterior crossbite. They showed that the children with UCLP in the mixed dentition tended to have more severe maxillary transverse constrictions. By expanding the maxilla, the collapse of the palatal segments is corrected. RME increases the maxillary dental arch widths, aligns the maxillary segments and provides space in the alveolar cleft for the bone graft.[13]

MacDonald et al.[22] used both Class I and Class III control groups to assess the outcome of expansion and protraction therapy. He observed that the Class I control group had more maxillary and less mandibular growth-induced forward movement. Tindlund et al.[19] stated, normal growth, directed forward and downward is hard to be expected in the underdeveloped maxilla, especially in the cleft patients. Sade Hoefert et al.[16] used Class I control group in their study to assess the outcome of expansion and protraction therapy in 29 patients. The results found were less pronounced because of the comparison with a normal growth control. On the other hand, it is ethically questionable whether patients with progressive Class III malocclusion requiring treatment should be recruited to create a control group. Therefore, in the study, we used noncleft Class I patients with a maxillary transversal deficiency for the control group.

To obtain orthopedic and orthodontic effects of RME, the age factor is very important. Bell et al.[23] stated, RME in primary and mixed dentition period may cause orthopedic effects.[7] Haas[24] investigated an appliance, and published many articles and mentioning that dentoalevolar effects in post-growth period. Baccetti et al.[8] made pubertal growth predictions based on cervical vertebrae. These predictions stated that in the studies where the Haas appliance was used, the orthopedic effects are seen in the prepubertal period, dentoalveolar and orthopedics effects are seen in the pubertal period, and the orthodontic effects are seen in the postpubertal period. There is a significant connection between the age of the patient and the amount of the expansion on the maxilla. In the prepubertal period or pubertal period, the maxilla shows the most significant changes with RME.[4],[12],[13],[14],[15],[16],[17],[25],[26],[27],[28] With the significance of these studies, we chose patients aged between 8 and 11, with mixed dentition and are in either prepubertal or pubertal period.

Different modified appliances are used for RME.[3],[23],[29] This appliance should be easy to clean and should not irritate tongue and the soft tissues. The appliance construction stages should be simple and cost minimal. The teeth should be strong enough for the anchorage, and the oral hygiene should be adequate.[11],[29]

While using the RME appliance, Haas used bands on the first premolars and first molars, then bonded the steel wire to the acrylic block to be in contact with the soft tissues, thus combining the segments together.[29] The Hyrax is another appliance to expand the maxilla where occlusal surfaces of the teeth are covered with Cr-Co alloy. In the study, we have chosen to use teeth supported acrylic bonded Hyrax appliance because it is easier to apply to the cleft patients and has better stability.

Holberg et al.,[5] Pan et al.,[30] and Gautam et al.[31] found that the displacement amount at the cleft side was greater than the noncleft side. Furthermore, posterior expansion was greater than the anterior expansion.

Façanha et al.[3] compared Haas and Hyrax expanders in UCCLP patients and found similar changes while studying dental models. Haas and Hyrax appliances produce significant increases of maxillary transversal widths. The expansion of the maxilla occurred in a pyramid shape, with the base located at the oral side, increasing the cleft area according to clinical and finite element model studies.

Mølsted and Dahl[6] used posteroanterior cephalograms to compare the CLP patients with cleft lip patients and found that both groups have similar basal maxillary widths. However, unilateral CLP patients have less maxillary height and width on the effected side and the lower part of the nasal septum is inclined toward the effected side.

In the study, we evaluated the posteroanterior cephalograms, all groups showed statistically significant increase (P < 0.001) in width between the right and left first molars (Um-Um'). During skeletal expansion of maxilla with help of RPE, our data shows a statistical significance in more width between the maxillary molars. Thus, transversal widening of the maxilla is more than the basal part. The researchers pointed out that the reason is because the rotation of the maxillary segment in the frontal plane, alveolar flection, and tipping of the teeth.[10],[11],[24],[32] In this study, our goal was to come over the posterior crossbite.

CLP has a great impact on the nasomaxillary complex, it reduces internal nasal dimensions, increases resistance to respiratory airflow, causing oral breathing.[33],[34] The result is compromised lower airway functions.

Kyrkanides et al.[18] studied the nasomaxillary asymmetry on unilateral CLP patients with posteroanterior cephalograms. They found that the skeletal asymmetry comes to its peak level in the pubertal breakthrough. Anterior nasal spine and nasal septum deviate toward the noneffected side of the nasal cavity.

Haas[11] and Wertz and Dreskin[32] suggest improvement in nasal breathing as one of RME effects because of the transversal movement of the lateral nasal walls.

In the present study, the posteroanterior cephalograms were taken from all three groups to evaluate the differences that RPE causes. The measurements in the cephalograms showed a statistically significant increase (P < 0.001) skeletally on nasal width measurements (Ln-Ln') and maxillary width measurements (Mx-Mx'). This shows that the nasal cavity width increases with RME and the statistically significant increase is found in maxillary width. Most of the researchers found results, which supports these results.[25],[34]

In this study, especially in BCCLP group, maxillary width measurements were greater according to the control group and also UCCLP group. At the same time, nasal width measurements were greater in cleft groups, especially in BCCLP. After the expansion period was complete, all the patients emphasized their oral breathing was improved.

Hearing and speaking are also affected in CLP patients.[35],[36] The infections repeating in the middle ear, neuromuscular disturbances, cerebral malformations, anatomical variations of the palate, velopharyngeal failure are all risk factors for nasal speech.[33],[35],[36]

After their expansion period was complete, some of the patients mentioned an improvement on their pronunciation.[35],[36] To evaluate speech scientifically, we need more studies where speech is evaluated before and after RME treatment.


  Conclusion Top


RME produces similar changes in patients with CLP compared with noncleft patients, including significant increases of maxillary arch and nasal width measurements and buccal tipping of the maxillary posterior teeth. Transverse maxillary deficiency is frequently observed in patients with CLP and usually treated by RPE. When the facial morphologies were evaluated anteroposteriorly on UCCLP and BCCLP patients after RPE, the facial width measurements of the BCCLP patients showed much higher increases than the UCCLP and the control group. Compared to the control group, the nasal width measurements were much higher in CLP groups, which may also have an effect on breathing and speaking on CLP patients.

In addition, further studies relating with RME in patients with CLP would be beneficial, especially on breathing and speaking on CLP patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

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