ORIGINAL ARTICLE

Cone-beam computed tomography

evaluation of bone plate and root
length after maxillary expansion using
tooth-borne and tooth-tissue-borne
banded expanders
Mariana Roennau Lemos Rinaldi,a Fabiane Azeredo,a Eduardo Martinelli de Lima,a Susana Maria Deon Rizzatto,a
Glenn Sameshima,b and Luciane Macedo de Menezesa
Porto Alegre, Rio Grande do Sul, Brazil, and Los Angeles, Calif

Introduction: The objective of this research was to evaluate the buccal bone plate and root length of maxillary
permanent first molars using cone-beam computed tomography after maxillary expansion with different
activation protocols. Methods: Cone-beam computed tomography images of growing patients were obtained
from the orthodontic department of Pontifical Catholic University of Rio Grande do Sul in Brazil. The groups
were Haas-type 2/4 turns, Haas-type 4/4 turns, hyrax-type 2/4 turns, and hyrax-type with alternate rapid
maxillary expansions and constrictions (alt-RAMEC) 4/4 turns a day. Tooth length, periodontal insertion,
alveolar bone thickness, and intermolar distances were evaluated. The data at the start of treatment and
6 months later were compared using generalized linear models. The intergroup differences were determined
by univariate analysis of variance with the Bonferroni adjustment. Results: Tooth length was significantly short-
ened after expansion in all groups (
0.28 to
0.51 mm), except for the alt-RAMEC group. Bone level variables
(bone level and bone level at the tooth tip) changed statistically in all groups, except for the Haas 4/4 turns group.
There was significant periodontal attachment loss after rapid maxillary expansion with the hyrax/alt-RAMEC
(5.09 mm). The hyrax/alt-RAMEC and hyrax groups had more dehiscences, fenestrations, and exposures of
the root. Conclusions: The consequence of rapid maxillary expansion using the hyrax was alveolar bone
resorption, especially in the hyrax/alt-RAMEC group, whereas the Haas expander caused mild root
resorption. (Am J Orthod Dentofacial Orthop 2018;154:504-16)

T
he maxillary expansion procedure is widely used to
correct posterior maxillary transverse discrepancies
that are usually associated with different kinds of
malocclusion, such as a Class II or Class III molar relation-
ship, open bite, or crowding.1-7 Early treatment of this
condition offers the possibility of orthopedic correction
a
Department of Orthodontics, School of Dentistry, Pontifical Catholic University
of Rio Grande do Sul, Porto Alegre, Brazil.
b
Advanced Dental Education Program in Orthodontics, Herman Ostrow School of
Dentistry, University of Southern California, Los Angeles.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Supported by the doctoral fellowships program of the Coordenaç~ao de Aperfei-
çoamento de Pessoal de Nıvel Superior, Brazil.
Address correspondence to: Luciane Macedo de Menezes, Av. Ipiranga, 6681,
Predio 6 (Faculdade de Odontologia), Porto Alegre, RS CEP 91530-000, Brazil;
e-mail, luciane.menezes@pucrs.br.
Submitted, August 2017; revised and accepted, December 2017.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.12.018
504
by the separation of the midpalatal, circumzygomatic,
and circumaxillary sutures. The aims of the transverse
correction during the mixed dentition are to eliminate
arch length discrepancies and basal bone deficiencies
and to facilitate facemask protraction.8-10 However,
Liou and Tsai8 proposed an alternative method for disar-
ticulation of the circumaxillary sutures using alternate
expansion and constriction (alt-RAMEC) of the maxillary
arch. They reported that the maxillary sutures were
less disarticulated using conventional rapid maxillary
expansion (RME) compared with the alt-RAMEC
method. In addition, the facemask therapy associated
to the alt-RAMEC procedure was 3 times more effective
to displace A-point anteriorly than with RME in a
sample of growing Class III patients with cleft lip and
palate.8
The orthopedic expansion is obtained when a high-
force system is applied on the midsagittal maxillary
suture using tooth-tissue-borne (Haas type) or tooth-
Lemos Rinaldi et al
borne (hyrax type) appliances. Heavy forces such as 10
kilogram-force generated during a turn of the expander
screw11 are responsible for transverse skeletal changes
with suture opening and minimum orthodontic move-
ment.1,12,13
The application of orthodontic forces induces a local
process of inflammation, which is essential for tooth
movement. This biomechanical reaction includes the 4
cardinal signs and symptoms of inflammation: redness,
heat, swelling, and pain.14 Although orthodontically
induced root resorption is an undesirable risk of treat-
ment, it is considered an unavoidable consequence of
the forces applied for tooth movement.14,15 No
regeneration is possible when the tooth root loses
apical tissue beneath the cementum layers14; however,
root resorption severe enough to create a clinical prob-
lem is unusual in orthodontics.16
Previous studies have reported RME with root resorp-
tion and evaluated this phenomenon with different im-
aging techniques such as radiographs,17 histologic
analysis,18,19 scanning electron microscope,20 and
cone-beam computed tomography (CBCT).21 Conven-
tional computed tomography and CBCT have also
been used for skeletal, dentoalveolar, and periodontal
change analyses resulting from maxillary expan-
sion.22-27 Some studies have indicated that RME can
change the buccal cortical bone level23,28,29 and cause
root resorption,21 but no studies have compared how
different RME screw activation protocols can affect
both bone level and root length.
The aim of this study was to evaluate the buccal bone
plate and root length of maxillary permanent first molars
using CBCT in 4 groups of patients, divided according to
their treatment protocols for RME.
MATERIAL AND METHODS
The ethical committee of the Pontifical Catholic Uni-
versity of Rio Grande do Sul in Brazil approved this
study. A sample of growing patients was selected from
the database of previous randomized clinical trials in
the Department of Orthodontics at the School of
Dentistry, with random allocation of each subject to
the groups.
The inclusion criteria for the study were transverse
maxillary deficiency, mixed or early permanent denti-
tion, and no surgical or other treatment that could inter-
fere with the RME effects during the expansion period.
Patients with congenital malformations, periodontal
diseases, or metallic restorations in the permanent first
molars were excluded.
CBCT images were taken before treatment (T1) and
6 months after jackscrew stabilization (T2). The images
were taken using an i-CAT scanner (Imaging Sciences
American Journal of Orthodontics and Dentofacial Orthopedics
505
International, Hatfield, Pa) at 120 kV, 8 mA, scanning
time of 40 seconds, and 0.3-mm voxel dimension. The
data for each patient were saved in DICOM format,
and the images were stored in compact disks.
The CBCT data of 77 patients of the original sample
were analyzed, and 16 examinations were excluded
because the roots of the permanent first molars were
incomplete at the apical third when the initial CBCT
were taken. Therefore, the total sample size of this study
consisted of 61 children, distributed as described in
Table I.
The patients were distributed in 4 groups, according
to the daily screw activation protocol and expander ap-
pliances used for RME: Haas-type 2/4 turns (n 5 11),
Haas-type 4/4 turns (n 5 16), hyrax-type 2/4 turns
(n 5 18), and hyrax-type with alternate rapid maxillary
expansions and constrictions (alt-RAMEC) activation
protocol with 4/4 turns a day (n 5 16) (Table I).
A complete turn of the screw was done at the instal-
lation of the appliance in all groups (0.8 mm). The pa-
tients of the alt-RAMEC group were instructed to
perform screw activation for a week and deactivation to-
wards closing at the same daily rate over the next week.
Maxillary expansions and constrictions were repeated
for 7 weeks in this hyrax-type group.
Activations were performed until up to 8 mm of
expansion in the Haas-type 2/4, Haas-type 4/4, and
hyrax-type 2/4 groups. The alt-RAMEC group had a total
of 6.4 mm of screw opening. Overcorrection of the trans-
verse dentoskeletal discrepancy in all groups was
achieved. At the end of the RME active phase, the screws
were stabilized, and all patients used the same expanders
for 6 months during the retention period.
The CBCT analysis was performed using the InVivo5
software program (Anatomage Dental, San Jose, Calif) as
similarly proposed by Bernd.30 The region of the perma-
nent first molar was evaluated. The long axis of the me-
siobuccal root of the maxillary permanent first molar was
used as the reference for the standardization of the CBCT
images taken at T1 and T2 (Fig 1; Table II).
In the axial view, using the Section mode tool in the
InVivo5, the reference line (horizontal) available in the
program was positioned at the center of the mesiobuccal
root of the maxillary first molar (Fig 1, A). In the sagittal
view, the reference line (vertical) was positioned on the
long axis of the mesiobuccal root of the tooth (Fig 1,
B), resulting in a coronal image with adequate visualiza-
tion of the alveolar buccal cortical bone and molar root
axis to be measured (Fig 1, C and D). Then the reference
line (vertical) was also placed on the long axis of the me-
siobuccal root of the maxillary first molar (Fig 1, C). The
reference protocol for the CBCT analysis was based on
the individual positioning of each tooth, and this step
October 2018  Vol 154  Issue 4
506 Lemos Rinaldi et al

Table I. Distribution of the 4 groups of patients

Group n Boys Girls Mean age (y 6 SD) RME activation protocol (mm/day) Total activation (mm)
Haas 2/4 11 2 9 11.6 6 1.5 0.4 8.0
Haas 4/4 16 6 10 11.3 6 1.7 0.8 8.0
Hyrax 18 7 11 11.1 6 1.25 0.4 8.0
Hyrax/alt-RAMEC 16 10 6 10.3 6 1.98 0.8 6.4
Total 61 25 36 11.0 6 1.6 - -

Fig 1. CBCT slices were oriented using the software program tools, and dentoalveolar variables were
measured: A, in the axial view, the reference line was positioned on the center of the mesiobuccal root
of the maxillry permanent first molar at the right side (horizontal line); B, in the sagittal view, the refer-
ence line (vertical line) was positioned on the long axis of the mesiobuccal root of the tooth; C, as the
result of axial and sagittal repositioning, a coronal image was obtained; D, dentoalveolar variables eval-
uated (TL, BL, BLC, B5, and B10).

was repeated according to the orientation of the right
and left molars.
Transverse measurements were also made. CBCT im-
ages were reoriented with the Frankfort horizontal plane
parallel to the floor in the sagittal view. In addition, the
infraorbital plane, formed by a line tangent to the lowest
point on the inferior margin of the bony orbits and par-
allel to the floor, was used as a reference plane in the cor-
onal aspect. Then the intermolar widths were evaluated
at 2 vertical levels: the trifurcation and the cuspal
regions of the maxillary permanent first molars (Fig 2).
In the axial view, the trifurcation region was used as
an anatomic reference at the level where the mesial
and distal roots are separated. Thus, intermolar root
width (IRW) was the distance between the buccal sur-
faces of the mesiobuccal root canals of the maxillary
right and left permanent first molars, measured in the
axial view at the trifurcation level (Fig 2, A). At the
same sagittal position, however, in the coronal view,
the intermolar cuspal width (ICW) was the distance

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Lemos Rinaldi et al 507

Table II. Linear measurements at T1 and T2 used to analyze RME dentoalveolar effects
Measurement Definition
TL Tooth length Distance between the tip of mesiobuccal cusp to the apex of the
mesiobuccal root of the maxillary first molar
BL Buccal alveolar bone level Distance from the buccal cementoenamel junction and the most
cervical portion of the buccal alveolar bone crest
BLC Buccal bone level to the cusp tip Distance from the buccal cusp tip to the buccal alveolar crestal bone.
B5 Alveolar bone thickness 5 mm from cementoenamel junction Distance between the outer surface of the mesiobuccal root of the
maxillary first molar and the outer surface of the buccal cortical
bone, perpendicular to the tooth length line.
B10 Alveolar bone thickness 10 mm from cementoenamel junction Distance between the outer surface of the mesiobuccal root of the
maxillary first molar and the outer surface of the buccal cortical
bone, perpendicular to the tooth length line.
IRW Intermolar root width Transverse distance between the maxillary right and left first molars
at the furcation level, in the axial view.
ICW Intermolar cuspal width Transverse distance between the tips of the right and left mesiobuccal
cusps of the maxillary first molars, in the coronal view.

Fig 2. Three-dimensional CBCT slices used for intermolar measurements: A, intermolar root width
(IRW) measured at the trifurcation region (axial view); B, in the sagittal view, the reference line (vertical
line) was positioned on the long axis of the mesiobuccal root of the maxillry first molars; C, intermolar
cuspal width (ICW) measured at the mesiobuccal cusp tips of the maxillary permanent first molars (cor-
onal view).

between the mesiobuccal cusp tips of the reference teeth
(Fig 2, C), similar to the method proposed by Rungchar-
assaeng et al.31
Statistical analysis
Intraexaminer reliability of the measurements was
determined by intraclass correlation coefficients. CBCT
images of 10 patients were randomly selected, and dou-
ble assessments of each parameter at T1 and T2 were
performed by the same operator (M.R.L.R.) at a 10-day
interval.
Means and standard errors for all parameters and the
ICW/IRW ratio were calculated, and data at T1 and T2
were compared using generalized linear models.
Intergroup statistical analyses of the mean differences
between T1 and T2 were determined by univariate anal-
ysis of variance, controlling the initial variations among
the groups, with Bonferroni adjustments at a signifi-
cance level of 5%.
RESULTS
The mean ages of the patient groups are described in
Table I, and no statistically significant difference was
found among them.
The measurements of all variables were considered
reliable, and the intraclass correlation coefficient values
ranged from 0.87 to 0.99.

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508 Lemos Rinaldi et al

Table III. Tooth mean length, and minimum, maximum, and mean differences among groups between T1 and T2
Mean difference T2-T1 (95% CI) Mean difference
T1 mean (SD) T2 mean (SD) P* (minimum; maximum) Group (groups) Py
TL
Haas 2/4 19.20 (1.0) 18.80 (0.93) 0.000
0.40 (
0.60;
0.18) Haas 4/4 0.11 1.00
Hyrax
0.12 1.00
Hyrax/alt–RAMEC
0.22 1.00
Haas 4/4 20.17 (1.61) 19.66 (1.66) 0.000
0.51 (
0.69;
0.33) Haas 2/4
0.11 1.00
Hyrax
0.23 0.55
Hyrax/alt–RAMEC
0.33 0.13
Hyrax 20.08 (1.41) 19.80 (1.48) 0.000
0.28 (
0.42;
0.12) Haas 2/4 0.12 1.00
Haas 4/4 0.23 0.55
Hyrax/alt–RAMEC
0.1 1.00
Hyrax/alt-RAMEC 19.51 (1.63) 19.33 (1.38) 0.159
0.18 (
0.43;
0.07) Haas 2/4 0.21 1.00
Haas 4/4 0.33 0.13
Hyrax 0.1 1.00

Statistically significant (P #0.05).

*Generalized estimating equations. Bonferroni adjustment for multiple comparisons; yAnalysis of covariance adjusted for baseline values. Each
Wald chi-square test evaluates the simple effects of time on each level of the combination of other factors shown. These tests are based on the
linearly independent pairwise method comparisons between estimated marginal means.

Tooth length was significantly shortened after treat-
ment in all groups, except in the hyrax/alt-RAMEC
group. Nonetheless, the mean difference among the 4
groups showed no significant difference (Table III;
Fig 3). Buccal alveolar bone level (BL) increased signif-
icantly in the 4 groups, especially in the hyrax/alt-
RAMEC group (5.09 mm) (Fig 3). Buccal cortical bone
level at the cusp tip (Fig 3) also increased significantly,
except in the Haas 4/4 group, and alveolar bone thick-
ness (B5 and B10) decreased significantly in the 4
groups (Table IV; Fig 3).
Both the IRW and ICW variables showed statistically
significant differences between T1 and T2 in all 4
groups. The Haas 2/4 group had the greatest mean dif-
ference between T1 and T2 for IRW and ICW (7.12 and
9.16 mm, respectively; Fig 3). The IRW mean for the
Haas 2/4 group was statistically greater than the means
obtained for the Haas 4/4 and hyrax/alt-RAMEC groups
(5.46 and 5.13 mm, respectively; Table V).
The lowest mean difference between pretreatment
and posttreatment ICW was found in the Haas 4/4 group
(6.46 mm), and it was significantly different from the
Haas 2/4 and hyrax groups (Table V; Fig 4).
The ICW/IRW ratios were significantly different for all
4 groups when the difference between the treatment pe-
riods was compared (T2-T1). Buccal inclination of the
molars at the cuspal level was higher than at the root
level. No statistical difference was observed among the
groups (Table V; Fig 3). Significant differences were
observed after the RME procedure with the Haas and
hyrax appliances. However, the buccal cortical bone
levels were significantly increased in the hyrax groups
(Table VI).
In addition, anatomic defects related to the maxillary
permanent first molars and their adjacent buccal cortical
plates were observed at T2 in the CBCT scans, probably
because of the RME procedure (Fig 5). These undesired
findings were classified and quantified with their per-
centages in Table VII.
DISCUSSION
Apical root resorption is frequently associated with
orthodontic movement. The literature supports the vari-
ability of its incidence due to individual predispositions
(genetic factors), deleterious habits (eg, tongue thrust),
increased overjet, and susceptibility to traumatic dental
injuries especially to the maxillary incisors, as well as
forces applied during orthodontic procedures.32-36
Root resorption can be influenced by root shape when
the apical thirds are triangular, pipette shaped,
dilacerated, or short.14 External root resorption is
considered severe when it exceeds 4 mm or one third
of the original root length,33,37,38 or up to 30% of root
loss. Another important factor is the number of teeth
involved; short roots of all 4 anterior teeth have higher
risks for future problems with additional insertion
loss.31 The major concern related to root resorption is
the dental insertion loss, compromising the maintenance
of the tooth.33,39-41
In this study, the mesiobuccal root was analyzed
because this root is directly related to the buccal bone
plate. This root is bulkier than the distobuccal root and
more susceptible to dentoskeletal changes related to
RME.
Root resorption associated with RME was previously
studied by invasive methods, extracting premolars after

October 2018  Vol 154  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Lemos Rinaldi et al 509

Fig 3. Comparison between groups after RME. Generalized estimating equations with the Bonferroni
adjustment for multiple comparisons were used, and analysis of covariance was adjusted for baseline
values. Each Wald chi-square test evaluates the simple effects of time on each level of the combination
of other factors shown. These tests were based on the linearly independent pairwise method compar-
isons between estimated marginal means. Groups not connected by the same letter are significantly
different (P #0.05). *Statistically significant between T1 and T2.

expansion and observing the roots by optical microscopy used as anchorage after RME. Other authors reported
or scanning electron microscopy and, more recently, by that root damages were more associated with teeth
CBCT images.18,19,21,42 Barber and Sims42 reported with longer periods of fixed retention; in the repaired
resorption of the buccal surface of the roots of premolars resorptive defects, cellular cementum with Sharpey's

American Journal of Orthodontics and Dentofacial Orthopedics October 2018  Vol 154  Issue 4
510 Lemos Rinaldi et al

Table IV. Means and differences among groups between T1 and T2 for BL, BLC, B5, and B10
Mean difference T2-T1 (95% CI) Mean difference
T1 mean (SD) T2 mean (SD) P* (minimum; maximum) Group (groups) Py
BL
Haas 2/4 1.25 (0.40) 2.53 (2.26) 0.003 1.28 (0.44; 2.12) Haas 4/4 1.05 1.00
Hyrax
0.52 1.00
Hyrax/alt-RAMEC
3.80* 0.00
Haas 4/4 1.24 (0.31) 1.47 (0.61) 0.020 0.23 (0.03; 0.41) Haas 2/4
1.05 1.00
Hyrax
1.57 1.00
Hyrax/alt-RAMEC
4.86* 0.00
Hyrax 1.08 (0.32) 2.88 (3.46) 0.002 1.80 (0.68; 2.89) Haas 2/4 0.52 1.00
Haas 4/4 1.57 1.00
Hyrax/alt-RAMEC
3.29* 0.00
Hyrax/alt-RAMEC 1.31 (0.29) 6.40 (5.33) 0.000 5.09 (3.31; 6.87) Haas 2/4 3.90* 0.00
Haas 4/4 4.86* 0.00
Hyrax 3.29* 0.00
BLC
Haas 2/4 8.26 (0.78) 9.51 (2.29) 0.003 1.24 (0.43; 2.06) Haas 4/4 1.14 1.00
Hyrax
0.74 1.00
Hyrax/alt-RAMEC
4.10* 0.00
Haas 4/4 8.06 (0.71) 8.16 (0.90) 0.377 0.10 (
0.12; 0.33) Haas 2/4
1.14 1.00
Hyrax
1.88 0.14
Hyrax/alt-RAMEC
5.24* 0.00
Hyrax 8.14 (0.69) 10.12 (3.79) 0.001 1.98 (0.86; 3.09) Haas 2/4 0.74 1.00
Haas 4/4 1.88 0.14
Hyrax/alt-RAMEC
3.36* 0.00
Hyrax/alt-RAMEC 7.75 (0.81) 13.09 (5.32) 0.000 5.34 (3.59; 7.09) Haas 2/4 4.10* 0.00
Haas 4/4 5.24* 0.00
Hyrax 3.36* 0.00
B5
Haas 2/4 1.95 (0.55) 0.60 (0.46) 0.000
1.35 (
1.54;
1.15) Haas 4/4
0.57* 0.00
Hyrax
0.45* 0.03
Hyrax/alt-RAMEC
0.27 0.56
Haas 4/4 1.71 (0.54) 0.93 (0.42) 0.000
0.78 (
0.97;
0.59) Haas 2/4 0.57* 0.00
Hyrax 0.12 1.00
Hyrax/alt-RAMEC 0.30 0.25
Hyrax 1.80 (0.98) 0.90 (0.82) 0.000
0.90 (
1.12;
0.69) Haas 2/4 0.45* 0.03
Haas 4/4
0.12 1.00
Hyrax/alt-RAMEC 0.18 1.00
Hyrax/alt-RAMEC 1.42 (0.68) 0.34 (0.50) 0.000
1.08 (
1.26;
0.89) Haas 2/4 0.27 0.56
Haas 4/4
0.30 0.25
Hyrax
0.18 1.00
B10
Haas 2/4 3.16 (1.59) 1.88 (1.48) 0.000
1.28 (
1.92;
0.64) Haas 4/4
0.17 1.00
Hyrax 0.30 1.00
Hyrax/alt-RAMEC 0.37 1.00
Haas 4/4 3.03 (1.11) 1.92 (1.25) 0.000
1.11 (
1.42;
0.78) Haas 2/4 0.17 1.00
Hyrax 0.47 1.00
Hyrax/alt-RAMEC 0.54 0.98
Hyrax 3.37 (2.15) 1.79 (1.38) 0.000
1.58 (
2.11;
1.03) Haas 2/4
0.30 1.00
Haas 4/4
0.07 1.00
Hyrax/alt-RAMEC 0.17 1.00
Hyrax/alt-RAMEC 2.52 (2.14) 0.87 (1.23) 0.000
1.65 (
2.25;
1.05) Haas 2/4
0.37 1.00
Haas 4/4
0.54 0.98
Hyrax
0.07 1.00
Statistically significant (P #0.05).
*Generalized estimating equations. Bonferroni adjustment for multiple comparisons; yAnalysis of covariance adjusted for baseline values. Each
Wald chi-square test evaluates the simple effects of time on each level of the combination of other factors shown. These tests are based on the
linearly independent pairwise method comparisons between estimated marginal means.

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Lemos Rinaldi et al 511

Table V. Means, and minimum, maximum, and mean differences among groups between T1 and T2 for IRW, ICW
and ICW/IRW ratio
Mean difference T2-T1 (95% CI) Mean difference
T1 mean (SD) T2 mean (SD) P* (minimum; maximum) Groups (groups) Py
IRW
Haas 2/4 44.98 (2.04) 52.10 (2.55) 0.000 7.12 (6.44; 7.79) Haas 4/4 1.66* 0.01
Hyrax 0.88 0.47
Hyrax/alt-RAMEC 1.99* 0.00
Haas 4/4 47.62 (2.59) 53.08 (2.42) 0.000 5.46 (4.8; 6.11) Haas 2/4
1.66* 0.01
Hyrax
0.78 0.54
Hyrax/alt-RAMEC 0.33 1.00
Hyrax 46.22 (2.61) 52.46 (3.08) 0.000 6.24 (5.62; 6.83) Haas 2/4
0.89 0.47
Haas 4/4 0.78 0.54
Hyrax/alt-RAMEC 1.11 0.10
Hyrax/alt-RAMEC 47.01 (4.20) 52.14 (4.41) 0.000 5.13 (4.54; 5.71) Haas 2/4
1.99* 0.00
Haas 4/4
0.33 1.00
Hyrax
1.11 0.10
ICW
Haas 2/4 46.24 (2.28) 55.40 (2.84) 0.000 9.16 (8.14; 10.18) Haas 4/4 2.70* 0.00
Hyrax 0.29 1.00
Hyrax/alt-RAMEC 1.77 0.10
Haas 4/4 48.99 (2.93) 55.45 (3.08) 0.000 6.46 (5.94; 6.97) Haas 2/4
2.70* 0.00
Hyrax
2.41* 0.00
Hyrax/alt-RAMEC
0.93 0.99
Hyrax 48.99 (2.34) 57.86 (3.12) 0.000 8.87 (8.08; 9.65) Haas 2/4
0.29 1.00
Haas 4/4 2.41* 0.00
Hyrax/alt-RAMEC 1.48 0.14
Hyrax/alt-RAMEC 48.92 (3.93) 56.31 (4.23) 0.000 7.39 (6.18; 8.58) Haas 2/4
1.77 0.10
Haas 4/4 0.93 0.99
Hyrax
1.48 0.14
ICW/IRW ratio
Haas 2/4 1.028 (0.04) 1.064 (0.05) 0.006 0.036 (0.01; 0.10) Haas 4/4 0.020 1.00
Hyrax
0.007 1.00
Hyrax/alt-RAMEC
0.004 1.00
Haas 4/4 1.029 (0.04) 1.044 (0.04) 0.024 0.015 (0.00; 0.29) Haas 2/4
0.020 1.00
Hyrax
0.028 0.31
Hyrax/alt-RAMEC
0.024 0.58
Hyrax 1.061 (0.05) 1.104 (0.05) 0.000 0.043 (0.03; 0.06) Haas 2/4 0.007 1.00
Haas 4/4 0.028 0.31
Hyrax/alt-RAMEC 0.003 1.00
Hyrax/alt-RAMEC 1.042 (0.04) 1.082 (0.06) 0.002 0.040 (0.01; 0.06) Haas 2/4 0.004 1.00
Haas 4/4 0.024 0.58
Hyrax
0.003 1.00

Statistically significant (P #0.05).

*Generalized estimating equations. Bonferroni adjustment for multiple comparisons; yAnalysis of Covariance adjusted for baseline values. Each
Wald chi-square test evaluates the simple effects of time on each level of the combination of other factors shown. These tests are based on the
linearly independent pairwise method comparisons between estimated marginal means.

fibers was observed.18,19 Studies have assessed
volumetric dimensions of dental roots after RME with
CBCT images.21,43 Baysal et al21 evaluated root resorp-
tion in 25 patients, and the 3-dimensional images of
the permanent first molars and first and second premo-
lars were cautiously segmented. The difference between
the before and after RME root volumes was statistically
significant for all roots investigated. The maximum vol-
ume loss was observed for the mesiobuccal roots of
maxillary first molars (18.60 mm3). The less affected
root was the distobuccal root of maxillary first molars
(9.47 mm3). In another study, the teeth were segmented
to measure their surface areas.43 The authors observed
loss of structure in the roots of the maxillary permanent
first molars and premolars after RME. The analyses
showed that the main locations of the changes were at
the apex of the maxillary teeth and the buccal aspect
of the roots.

American Journal of Orthodontics and Dentofacial Orthopedics October 2018  Vol 154  Issue 4
512
Fig 4. After RME, the ICW/IRW ratio showed that the
crowns were more buccally inclined than the furcation
level of the roots of the maxillary permanent first molars.
In our study, the Haas 4/4 group showed greater
amounts of resorption (0.51 6 0.09 mm), with no signif-
icant difference compared with the other groups
(Table III). The range of shortening observed was compa-
rable with the values found by Akyalcin et al43 in a sam-
ple of patients with tooth-borne RME appliances
(0.36-0.52 mm). Sameshima and Sinclair44 also found
resorption of the mesial buccal roots of first molars
after treatment with full fixed orthodontic appliances
(0.12 6 1.34 mm). The smallest root shortening
observed in our study was 0.18 6 0.12 mm for the
hyrax/alt-RAMEC group, with no statistical significance
(Table III).
The IRW and ICW measurements were related to the
amount of expansion, whereas the ICW/IRW ratio
referred to the tooth's buccal tipping. The maxillary
expansion had a triangular pattern with a wider base
at the cuspal level of the maxillary first molars. Signifi-
cant buccal inclination of the crowns was observed in
all groups, but it was greater in the hyrax and hyrax/
alt-RAMEC groups. The mean ICW values in both groups
were 44% (2.26 mm) and 42.1% (2.63 mm) higher than
IRW, respectively. The cuspal tipping amounts were
28.6% (2.04 mm) and 18.3% (1 mm) higher than root
buccal tipping for the Haas 2/4 and Haas 4/4 groups,
respectively (Fig 4). However, no significant difference
was found in the ICW/IRW ratio among the groups
(Table V; Fig 4).
The total amount of screw activation was standard-
ized at 8 mm for the Haas 2/4, Haas 4/4, and hyrax
groups (Table I). The results showed that buccal cusp
tipping in the Haas 2/4 group was 14.5% (1.16 mm)
greater than the expansion at the screw. Similar behavior
was observed in the hyrax group, where the ICW was
10.8% (0.87 mm) greater than the screw opening. How-
ever, the Haas 4/4 group had a smaller ICW (6.46 mm) in
October 2018  Vol 154  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Lemos Rinaldi et al
relation to the 8 mm activated at the expander screw.
The same comparison showed that buccal inclination
was 15.4% (0.99 mm) greater in relation to the
6.4 mm of total screw activation using the hyrax/alt-
RAMEC protocol. Maybe the clinical response using a
short-term activation protocol, as used in the Haas 4/4
group (with approximately 10 days of expansion), could
contribute to preventing excessive buccal tipping.
Buccal or palatal bone plate measurements were
inaccessible before the advent of CBCT. The accuracy
and reliability of this method to detect bone alterations
have been tested.45-47 Most studies agree that bone
measurements using CBCT have appropriate accuracy
and reliability for clinical studies. Nevertheless, the
accuracy of the measurements of alveolar bone height
and bone thickness are related to the voxel size.
Alveolar bone height loss might be overestimated with
a 0.4-mm voxel size of the CBCT. This situation can be
observed if the bone thickness is smaller than the
CBCT voxel size.48,49 By using a voxel size of 0.38 mm,
the alveolar bone height can be measured to an
accuracy of about 0.6 mm, and root fenestrations can
be identified with greater accuracy than dehiscences.
Sun et al49 found that dehiscences were systematically
overestimated on the CBCT measurements when the ver-
tical diameter of the dehiscence was over 3 mm. When a
fenestration was found on CBCT, they observed that the
alveolar defect was confirmed in approximately 20% of
the cases. Decreasing CBCT voxel size from 0.4 to
0.25 mm could improve the image accuracy for evalua-
tions of the alveolar bone and its adjacent structures.50
However, high-resolution CBCT images increase the pa-
tient's radiation dose, and it is important to consider
whether this is necessary for the diagnosis, treatment
plan, and clinical outcome.
Garib et al23 reported significant decreases in the
buccal bone plate thickness of the banded supporting
teeth (first premolars and permanent first molars) for
both tooth-tissue-borne and tooth-borne expanders,
ranging from 0.6 to 0.9 mm, after 3 months of expan-
sion. Brunetto et al28 compared RME with slow maxillary
expansion and reported loss and reduction of height and
thickness of bone in both groups.
In this study, bone thickness measurements (B5 and
B10) decreased significantly in all groups between T1
and T2, varying from 1.35 mm in B5 and 1.65 mm in
B10. The Haas 4/4 group had the lowest variation in
the measurements of bone plate height (BL and BLC)
and thickness (Table IV). The distance from the buccal
cementoenamel junction of the maxillary first molars
and the most cervical portion of the buccal alveolar
bone crest (BL) increased by a mean of 18.5%
(0.23 mm; P 5 0.020) in this group. Therefore, the
Lemos Rinaldi et al 513

Table VI. Means and mean differences among groups between T1 and T2
Mean difference T2-T1 (95% CI) Mean difference
T1 mean (SD) T2 mean (SD) P* (minimum; maximum) Expander types (expanders) Py
TL
Haas 17.33 (1.31) 17.86 (1.06) 0.000 0.53 (0.27; 0.77) Hyrax 0.07 1.00
Hyrax 17.69 (1.94) 18.15 (1.61) 0.005 0.46 (0.14; 0.78) Haas
0.07 1.00
BL
Haas 1.00 (0.47) 1.60 (1.43) 0.069 0.60 (
0.04; 1.23) Hyrax
1.21 0.80
Hyrax 0.11 (0.32) 2.92 (2.93) 0.039 1.81 (0.08; 3.52) Haas 1.21 0.80
BLC
Haas 7.70 (0.16) 8.46 (1.67) 0.000 0.76 (0.07; 1.44) Hyrax
1.68 0.29
Hyrax 7.97 (0.23) 10.41 (2.99) 0.000 2.44 (0.68; 4.19) Haas 1.68 0.29
B5
Haas 2.15 (0.71) 1.07 (0.68) 0.000
1.08 (
1.27;
0.87) Hyrax
0.29 1.00
Hyrax 1.84 (0.91) 0.54 (0.36) 0.000
1.30 (
1.70;
0.92) Haas 0.29 1.00
B10
Haas 4.70 (0.49) 2.68 (1.30) 0.000
2.02 (
2.78;
1.28) Hyrax 0.69 0.98
Hyrax 2.96 (0.67) 1.62 (1.02) 0.019
1.34 (
2.45;
0.22) Haas
0.69 0.98
IRW
Haas 46.86 (2.18) 52.56 (1.98) 0.000 5.70 (4.97; 6.43) Hyrax
0.90 1.00
Hyrax 46.45 (2.19) 53.05 (1.86) 0.000 6.60 (5.97; 7.24) Haas 0.90 1.00
ICW
Haas 48.21 (1.91) 57.63 (2.99) 0.000 9.42 (8.26; 10.58) Hyrax
1.31 1.00
Hyrax 49.20 (1.28) 59.93 (0.45) 0.000 10.73 (9.48; 11.98) Haas 1.31 1.00

Statistically significant (P #0.05).

*Generalized estimating equations. Bonferroni's corrected multiple comparisons; yAnalysis of covariance adjusted for baseline values. Each Wald
chi-square test evaluates the simple effects of time on each level of the combination of other factors shown. These tests are based on the linearly
independent pairwise method comparisons between estimated marginal means.

preservation of crestal bone seems to be related to the
lower buccal tipping. The BL increased by 388.5%
(5.09 mm; P 5 0.000) in the hyrax/alt-RAMEC group,
and it was significant compared with the other groups
(Table IV). A deleterious alveolar effect can be due to
the highest amount of buccal tipping of the crowns, re-
sulting in crestal bone resorption and loss of periodontal
attachment of anchored teeth in patients who used the
repetitive weekly protocol of alt-RAMEC and a rigid
expander appliance such as the hyrax.
In addition, occasional findings were observed in the
CBCT evaluations, and the hyrax/alt-RAMEC group
showed more dehiscences, fenestrations, and exposures
of the buccal aspect of the roots. The hyrax group also
had many subjects with these kinds of defects. It seems
to be related to the increased trend of buccal inclination
of the crowns after RME and the structural rigidity of the
appliance. Maybe the maxillary permanent first molars
and their adjacent alveolar bone could be preserved if
the deciduous first molars were banded and used as
anchorage instead of the permanent teeth.
The voxel size of the CBCT images used in this study
was 0.3 mm, and the measurements were taken on the
long axis of the coronal images, with clear visualization
of the alveolar buccal cortical bone and maxillary molar
roots, in both axial and coronal views. The hyrax/alt-
RAMEC protocol for RME was more prone to cause de-
fects at the buccal bone plate. Despite that, the hyrax/
alt-RAMEC group was the exception among the groups
evaluated. With no significant difference in tooth length
measurements between the treatment periods, it is plau-
sible that the expansion and contraction protocol might
have caused adverse effects to the bone plate in this
sample, but not to the roots, maybe because the amount
of expansion was smaller compared with the other
groups.
The Haas type of expander differs from the hyrax type
by the presence of an acrylic pad close to the palate to
reinforce the anchorage for a greater orthopedic
response during RME.12 In this study, both groups had
no statistically significant differences for any measure-
ment, except for B5, which was greater in the Haas-
type groups. This could be explained by the acrylic pad
against the palate, related to a more bodily movement
of the teeth, instead of inclination.23,28
Dental, skeletal, and periodontal stability in patients
after RME is a major concern for clinicians. According
to Phillips,39 2 mm of resorption at the apical root
length reduces the total insertion area of the root by
only 6% to 9%, and the apical loss of more than
2 mm can be equivalent to 1 mm of crestal bone
loss. Akyalcin et al26 found that the changes in the

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514 Lemos Rinaldi et al

Fig 5. Examples of anatomic defects related to the maxillary permanent first molars and adjacent alve-
olar bone tissue observed at T2, but not at T1: A, fenestration; B, dehiscence; C and D, complete
disruption of the buccal bone plate.

Table VII. Anatomic defects related to the maxillary permanent first molars and their adjacent cortical buccal plates
after RME
Anatomic defects

Number of teeth evaluated Dehiscence Fenestration Complete disruption Total % of teeth

Haas 2/4 22 2 1 1 4 18
Haas 4/4 32 0 0 0 0 0
Hyrax 36 5 6 1 12 33
Hyrax/alt-RAMEC 32 6 4 9 19 59
Total teeth 122 13 11 11 35 28

alveolar bone after RME were reversible in the long RME in patients with incomplete root development
term, with no evident deleterious effects to the alveolar of the maxillary permanent first molars and its relation-
buccal cortical bone. ship to the buccal bone plate shall be further

October 2018  Vol 154  Issue 4 American Journal of Orthodontics and Dentofacial Orthopedics
Lemos Rinaldi et al
investigated; since the number of patients with incom-
plete roots was small, those CBCT images were excluded
from this study.
An individual risk assessment for each patient is rec-
ommended before RME, and clinical examinations of the
periodontal conditions after RME should be considered
routine procedures.
CONCLUSIONS
1. Although the differences were not significant,
greater amounts of root resorption were found in
the Haas 4/4 group.
2. There were no statistically significant differences
among the Haas 2/4 and hyrax groups.
3. There was significant alveolar bone resorption and
consequent loss of attachment after RME with the
hyrax/alt-RAMEC compared with the other groups,
although no significant root resorption was
observed.
4. In general, the consequence of RME using the hyrax
appliance was alveolar bone resorption, whereas the
Haas appliance caused root resorption.
5. The hyrax/alt-RAMEC and hyrax groups had dehis-
cences, fenestrations, and exposure of the root at
the buccal aspect.
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