ArticlePDF Available

Abstract

Background: Pain suffered by the young patient is the most frequent symptom during orthodontic treatment and is the one that most frightens children and causes worry in their families. Aim: to investigate pain perception and function impairment during the first week of activation of two palatal expansion screws. Design: 101 subjects were randomly divided into two groups: RME group included patients treated with the standard hyrax expansion screw and LEAF group included patients treated with Leaf Expander appliance. Pain intensity was assessed via the Wong-Baker scale. A questionnaire on oral function impairments was also compiled by the patients. Results: The pain Scale analysis showed that patients in the RME group suffered from a significantly higher level of pain than those in the LEAF group (88.6% vs 25%, p<0.01). RME group showed highest pain indexes from day 1 to day 4 (51,4% RME vs 9,7% LEAF suffered at least once from strong pain in the first four days, p<0.01). Furthermore, oral functions were similarly affected in both groups. Conclusions: Pain reported during maxillary arch expansion is influenced by clinical activation protocol and by the screw type. Patients treated with Leaf Expander reported significantly lower pain level in the first 7 days of treatment.
Int J Paediatr Dent. 2020;00:1–8. wileyonlinelibrary.com/journal/ipd
|
1
© 2020 BSPD, IAPD and John Wiley & Sons A/S.
Published by John Wiley & Sons Ltd
1
|
INTRODUCTION
Maxillary arch expansion through a fixed appliance is a well-
known and consolidated practice in clinical orthodontics,
but current findings of ‘evidence-based dentistry’ have not
yet identified an ideal clinical expansion protocol. Recent
systematic reviews1,2 have shown that both rapid and slow
expansion protocols are clinically effective on the primary
outcome (ie, the resolution of the crossbite with a significant
increase of skeletal transversal dimension in the maxillary
transverse deficiency subjects). So, the choice of appliance
type solely based on its ability to solve maxillary constriction
issues is no longer the main selection criteria and the relevant
choice of the orthodontist should, therefore, be based on tim-
ing3,4 and on a ‘patient-oriented’ device, that can minimize
the various possible side effects, such as appliance break-
ages, functional impairments, injuries to the periodontal tis-
sues, and, of course, pain.5-12
Received: 1 July 2019
|
Revised: 22 December 2019
|
Accepted: 29 December 2019
DOI: 10.1111/ipd.12612
ORIGINAL ARTICLE
A multicenter, prospective, randomized trial of pain and
discomfort during maxillary expansion: Leaf expander versus
hyrax expander
AlessandroUgolini1
|
GianguidoCossellu2
|
MarcoFarronato2
|
ArmandoSilvestrini-Biavati1
|
ValentinaLanteri2
1Department of Surgical and Diagnostic
Sciences, University of Genova, Genoa,
Italy
2Department of Biomedical Surgical and
Dental Sciences, University of Milan,
Milan, Italy
Correspondence
Alessandro Ugolini, Department of
Orthodontics, University of Genoa, Largo
Rosanna Benzi 10, Pad. IV - 16132 Genova,
Italy.
Email: alessandro.ugolini@unige.it
Abstract
Background: Pain suffered by the young patient is the most frequent symptom
during orthodontic treatment and is the one that most frightens children and causes
worry in their families.
Aim: To investigate pain perception and function impairment during the first week
of activation of two palatal expansion screws.
Design: A total of 101 subjects were randomly divided into two groups: RME group
included patients treated with the standard hyrax expansion screw and LEAF group
included patients treated with Leaf Expander appliance. Pain intensity was assessed
via the Wong-Baker scale. A questionnaire on oral function impairments was also
compiled by the patients.
Results: The Pain Scale analysis showed that patients in the RME group suffered
from a significantly higher level of pain than those in the LEAF group (88.6% vs 25%,
P<.01). RME group showed highest pain indexes from day 1 to day 4 (51.4% RME
vs 9.7% LEAF suffered at least once from strong pain in the first 4days, P<.01).
Furthermore, oral functions were similarly affected in both groups.
Conclusions: Pain reported during maxillary arch expansion is influenced by clini-
cal activation protocol and by the screw type. Patients treated with Leaf Expander
reported significantly lower pain level in the first 7days of treatment.
KEYWORDS
leaf expander, maxillary expansion, pain, palatal expansion
2
|
UGOLINI et aL.
In orthodontic daily practice, pain suffered by the young
patient is the most frequent symptom during treatment and
is the one that most frightens children and causes worry in
their families.13 Available literature shows that rapid maxil-
lary arch expansion is, among the early orthodontic therapies,
the one with the highest incidences of pain (up to 98%) as an
adverse symptom reported by patients.5-9 Pain could be re-
lated to the rapid expansion protocol, during which, for each
activation of the screw (0.2 or 0.25mm) the force expressed
can reach up to 10 pounds. 14-18
In the relevant literature, prevention and management of
pain during palate expansion is a poorly analysed topic, de-
spite being a daily occurring problem in orthodontic clinical
practice5,6,19-21; thus, the present study aims at investigating
and analysing the perception of pain and function impairment
during the first week of activation with two palatal expan-
sion screws to identify the effect of different maxillary arch
expansion protocol on the pain perception and discomfort in
young patients.
2
|
MATERIALS AND METHODS
The present multicentric randomized study was conducted
at the Departments of Orthodontics of the Universities of
Milan and Genoa (Italy). The trial was first approved by the
Institutional Ethical Review Board (Fondazione IRCSS Ca'
Granda n° 936-1666/13) and published on Clini calTr ials.gov
(Clini calTr ials.gov Identifier: NCT03757468, https ://clini
caltr ials.gov/ct2/show/NCT03 757468). CONSORT docu-
ments, including a checklist and a flow chart, have been used
to report the findings.
One hundred and sixteen consecutive subjects with trans-
versal maxillary deficiency (intermolar width <30mm, with
or without crossbite) were randomly assigned to RME group
(treated with the standard hyrax expansion screw) or LEAF
group (treated with Leaf Expander appliance). The treating
clinician was blinded from the randomization procedure, but
because of clear differences in appliance design, blinding was
not possible during the treatment period itself. The data ex-
aminer was also blinded from the treatment protocol. Both
appliances were anchored on the second primary molars. All
subjects had a Class I or Class II dental malocclusion with
unilateral or bilateral crossbite and/or constricted maxilla
and were selected before the pubertal peak (cervical vertebral
maturation stage 1-3).
Patients with previous orthodontic treatment, hypodontia in
any quadrant excluding third molars, inadequate oral hygiene,
craniofacial syndromes, or cleft lip or palate were considered
ineligible for the study and thus duly excluded from it.
One hundred and one patients completed the study: 48
subjects were included in the RME group (23 males and
26 females, mean age 9.4years, range 6-13years) and 53
subjects in the LEAF group (25 males and 28 females, mean
age 9.1years, range 6-13years) (Table 1).
The RME group was treated with the standard hyrax expan-
sion screw anchored on second primary molars (Figure 1A).
When the appliance was in situ, the screw was initially turned
two times at chairside and then patients started the screw acti-
vation (Lancer Orthodontics) of two-quarter turns a day, one
in the morning and one in the evening (0.40mm/d) until over-
correction was achieved. Then, the RME remained in place
for approximately 9months.
The LEAF group was treated with Leaf Expander appliance
(Figure 1B) anchored on the second primary molars. A detailed
appliance description was reported elsewhere.22,23 Briefly, de-
sign of the Leaf Expander is similar to that of a conventional
rapid palatal expander with a double nickel-titanium leaf spring
instead of a midline jackscrew. The screws deliver a maximum
expansion of 6 or 10mm, by activating (compressing) the leaf
spring, which generates a constant force of 450g. The screw
was pre-activated in the laboratory to deliver the first 3mm
expansion, and then, re-activation was performed in the office
by 10-quarter turns of the screw per month until expansion has
been completed. One-quarter turn corresponds to 0.1 mm of
activation (10 activations of the screw generate 1mm of acti-
vation). The Leaf Expander was activated by the clinician only
and requires no compliance from the patients and their par-
ents. Active expansion and overcorrection generally take about
5-6 months after which the Leaf Expander should be main-
tained passively in place for 3months and then removed (after
a total time of 9months).
A questionnaire regarding oral/masticatory function
and a Wong-Baker Faces Pain Scale with a complemen-
tary numeric rating scale from 0 to 10 were compiled by
Why this paper is important to paediatric
dentists
Pain is the most frequent symptom during maxil-
lary arch expansion treatment and is the one that
most frightens children and causes worry in their
families.
• More than 50% of patients treated with the rapid
maxillary expander reported strong pain at least
once in the first 4days of treatment, whereas in
the Leaf Expander group, <10% of the subjects
suffered at least once from a level of pain indi-
cated as strong and the first 2days only.
• Pain suffered during maxillary arch expansion is
influenced by the choice of screw and activation
protocol, and Leaf Expander proved itself as an
effective and efficient expansion appliance in the
prevention of pain.
|
3
UGOLINI et aL.
each subject. Pain intensity was assessed using the Wong-
Baker scale24 from the first to the seventh day of the screw
activation, reporting a double registration per day (in the
morning and evening). The Wong-Baker scale is a tool for
self-assessment of pain intensity and is used in children
from 3years of age. The emojis range from the most smil-
ing, corresponding to ‘no pain perceived’, up to the cry-
ing emoji, corresponding to ‘worst pain imaginable’.9 Each
emoji is also paired with a number, from 0 to 10, which
coincides with the intensity of the pain. Verbal instructions
were given to the parent and child about how to correctly
assess pain. The child's pain response was measured 5min-
utes after each turn.5 Questionnaires also asked the patients
about eventual difficulties in swallowing and speaking, hy-
persalivation, analgesic consumption, and pain localization
(anterior teeth, anchored/posterior teeth, palatal vault, and
head) (Table 2).
2.1
|
Statistical analysis
Shapiro-Wilk's test showed that pain intensity data were
normally distributed, and parametric statistics were thus
applied. Descriptive statistics, median value, standard
deviation, and confidence interval (95% CI) were calcu-
lated. Differences between groups in pain intensity were
tested with parametric Student's t test, and risk ratio (RR)
analysis was performed to assess the questionnaire data.
Probabilities of <.05 were accepted as significant in all sta-
tistical analyses.
The sample size was calculated ‘a priori’ to obtain a sta-
tistical power of the study >.85 at an α of .05, using the mean
values and standard deviations of pain intensity during maxil-
lary arch expansion therapy found by Baldini and co-authors
(‘overall pain’: mean 0.80± 1.22 and 1.88±2.15)9 and re-
sulted in a minimum of 47 subjects for each group. Moreover,
TABLE 1 Flow of participants
Assessed for eligibility (n = 116)
Excluded (n = 0)
Other reasons (n = 0)
Analysed (n = 53)
Excluded from analysis (give reasons) (n = 0)
Lost to follow-up
Notcomplete the questionnaire (n = 3)
Allocated to intervention (LEAF) (n = 58)
Received allocated intervention (n = 56)
Did not receive allocated intervention (n = 2,
missed appointment)
Lost to follow-up
Not complete the questionnaire (n = 2)
Not follow the prescribed activation protocol) (n = 8)
Allocated to intervention (RME) (n = 58)
Received allocated intervention (n = 58)
Did not receive allocated intervention (give
reasons) (n = 0)
Analysed (n = 48)
Excluded from analysis (give reasons) (n = 0)
Allocation
Anal
y
sis
Follow-Up
Randomized (n = 114)
Enrollment
4
|
UGOLINI et aL.
a dropout of 20% was considered and the final sample size
comprised a minimum of 58 subjects for each group. The ef-
fect size (ES) coefficient (d)25 was also calculated. An ES
of .2-.3 might be a ‘small’ effect and thus a small clinically
significant difference, about .5 a ‘medium’ effect, and .8 to
infinity a ‘large’ effect.
3
|
RESULTS
Three patients in the LEAF group and two patients in the
RME group did not complete the questionnaire, and eight
subjects, all in the RME group, did not follow the pre-
scribed activation protocol at home. Two subjects in the
LEAF group missed the appointment and did not receive
the allocation. Fifteen subjects were thus excluded from
the study and the final sample comprised 101 subjects.
Crossbites and traversal maxillary discrepancy were en-
tirely corrected in 100% of the subjects at the end of the
expansion active phase.
The Wong-Baker Faces Pain Scale analysis showed
that patients in the RME group suffered from a signifi-
cant generalized sensation of pain during the first week
of screw activation compared to those in the LEAF group
(88.6% vs 25%, P< .01); moreover, in the RME group
25.2% of the patients reported analgesic consumption
(Table 3). Table 4 reports the pain perceived in the first
7 days of activation from both groups: patients treated
with the rapid maxillary expander reported a statistically
significant higher amount of pain in the first 4 days of
treatment (Table 4). In detail, RME group reported higher
pain indexes recorded on the Wong-Baker scale from day
1 to day 4 with a 51.4% of the patients indicated they suf-
fered at least once from a strong pain in the first 4days.
Patients treated with the Leaf Expander have instead a
statistically lower pain where only 9.7% of the subjects
of the LEAF group suffered from a level of pain indicated
as strong and in any case limited to the first 2days after
cementation and activation of the device, whereas the re-
maining 90% of the subjects report that they did not per-
ceive any pain in the first 2days of therapy. From the fifth
to the seventh day, the amount of pain reported was small
and did not differ significantly between the two groups
(Table 4). There were also no differences between the two
centres in the analysed variables.
Overall high scores of discomfort values in different oral
functions were reported (more than 80% of the sample re-
ported hypersalivation and difficulty in swallowing and
speaking) but did not differ between the groups (Table 3).
Subjects treated with RME have a significantly higher risk
of suffering pain from posterior teeth (RR=2.54, 95% IC:
1.51-4.28, P<.001), incisors (RR=3.3, 95% IC: 1.14-9.58,
P=.02), and taking pain medications (RR=11.14, 95% IC:
1.62-90.60, P<.01).
FIGURE 1 (A) Hyrax expansion appliance; (B) Leaf Expander
appliance
(A)
(B)
TABLE 2 Self-reported questions concerning pain and
discomfort, analgesic consumption in the first week of treatment
(modified from Feldman and Bazagani23)
1—Pain intensity
Do you now have pain? And for how many days?
Do you have pain from the molars?
Do you have pain from the incisors?
Do you have pain from the upper jaw?
Do you have pain from the palate?
Do you have pain from head?
Do you have pain during appliance activation?
2—Analgesic consumption
Have you used analgesics for pain from your jaws, teeth, or face?
If yes, what kind of analgesic and dosage did you use?
3—Jaw function impairment
If you have pain or discomfort in your teeth and jaws, how much
does that affect
Speaking
Salivation (hypersalivation)
Swallowing
|
5
UGOLINI et aL.
4
|
DISCUSSION
From a clinical point of view, correction of crossbites and
traversal maxillary discrepancy were achieved in all pa-
tients with both appliances. The jackscrew and the shape
memory leaf spring expander have different methods of
activation: the jackscrew or expansion screw (eg, hyrax) is
a telescoping appliance that requires several patient activa-
tions to achieve the maxillary arch expansion. The memory
leaf springs instead, due to their superelastic nature, re-
quired only a few activations or no activation at all because
of its reliance upon elastic restoration forces to achieve the
desired expansion. In the jackscrew, to a given amount of
screw turn corresponds a determined amount of expansion
(from 0.20 to 0.25 mm), so this allows clinicians to cal-
culate the number of activations required to achieve the
desired expansion. But it also suffers from several disad-
vantages because with each subsequent jackscrew activa-
tion the maxilla is subjected to a rapid increase in forces
and this is not only uncomfortable for the patient, but it
has also been suggested that high magnitude forces (up to
10 pounds) may result in a less pronounced physiologic
expansion of the suture.26 Another disadvantage for this
type of screw activation method is that it requires the pa-
tient (and parents) compliance to achieve the expansion:
in the present study, we had to exclude 14% (eight out 58)
of the subject of the RME initial sample because they did
not follow the recommended activation protocol in the first
week.27 Other complications during treatment (besides
those reported in the questionnaire) included mainly ap-
pliance breakage and decementation. All the complications
reported were lower in the LEAF group.
The main advantage with the shape memory leaf spring
is the continuous force application, similar to those of su-
perelastic NiTi wires. In fact, superelasticity is ‘the transfor-
mation from austenitic to martensitic that occurs by stress
application within a temperature range and is manifested by a
flat or nearly flat plateau in a force-deflection curve’.28 This
superelastic behaviour minimizes the number of rapid force
increments exerted on the tissue (and their magnitude as well)
which may lead to a more physiologic expansion and to an
increased feeling of comfort for the patients, as reviewed by
Romanyk et al.26 One disadvantage of the leaf-type activation
method is that longer time is required to achieve the expan-
sion (up to 6months), but the total time amount (9 months,
active expansion plus retention period) is equal to that with
rapid maxillary arch expansion.
The results of the present study on the pain perceived
during the maxillary arch expansion reflected the differences
between appliances in their biomechanical work and in the
release of the forces; in fact, overall pain during the first week
of the screw activation was significantly higher in the RME
group compared to the LEAF group (88.6% vs 25%, P=.01).
In detail, the subjects treated with the Leaf Expander reported
low pain level in the first 7days of activation (the appliance
was pre-activated to deliver the first 3 mm expansion) and
9.7% of the subjects suffered from a pain indicated as strong
at least once for the first 2days only after activation (the re-
maining 90.3% of subjects reported that they did not experi-
ence pain in the first 2days of therapy). Instead, the patient
in the RME (the screw activation was about 3mm in a week)
reported high pain level in the first 4days with a 51.4% (max-
imum peak in the second day) of the subjects that indicated
they suffered from severe pain at least once in the first 4days;
moreover, 25.2% of the patients in the RME group reported
analgesic consumption.
The results reported in the RME group were in accord
with those found in the literature 5,8,9,20,21 that found that
rapid maxillary expander was generally well tolerated with a
peak of pain perceived during the first 4days of the screw ac-
tivation with a complementary analgesic consumption (usu-
ally paracetamol or ibuprofen).21
TABLE 3 Discomfort and analgesic consumption in the first week of therapy
RME (%) LEAF (%)
Relative risk
ratio 95% CI Significance level
Difficulty in swallowing 79.2 84.9 0.93 0.77-1.12 .74
Hypersalivation 81.3 79.2 1.02 0.84-1.24 .8
Difficulty in speaking 87.5 92.5 0.94 0.82-1.07 .41
Pain—posterior teeth 62.5 24.5 2.54 1.51-4.28 <.001***
Pain—incisors 25.0 5.7 3.31 1.14-9.58 .02*
Pain—palatal vault 12.5 3.8 3.12 0.70-15.63 .13
Pain—head 8.3 0.0 4.43 0.51-38.15 .17
Analgesic consumption 25.2 0.0 11.14 1.62-90.60 .01**
*P=.05;
**P=.01;
***P=.001.
6
|
UGOLINI et aL.
TABLE 4 Pain intensity reported on the Wong-Baker Faces Pain Scale; Student's t test for independent samples
Day 1 M Day 1 E Day 2 M Day 2 E Day 3 M Day 3 E Day 4 M Day 4 E Day 5 M Day 5 Day 6 M Day 6 E Day 7 M Day 7 E
RME group
Mean 1.9 2.1 2.7 2.9 2.4 2.2 1.6 1.5 0.9 1.0 0.9 0.7 0.7 0.9
SD 1.0 1.1 1.2 1.1 1.0 1.0 1.0 1.1 1.2 0.9 0.9 0.8 0.5 0.6
CI 95% 0.2 1.8 2.3 2.6 2.1 1.9 1.3 1.1 0.6 0.7 0.6 0.5 0.5 0.8
0.3 2.4 3.1 3.2 2.7 2.5 1.8 1.8 1.3 1.3 1.1 0.9 0.9 1.1
LEAF group
Mean 0.8 1.3 1.2 1.2 0.8 0.8 0.7 0.7 0.6 0.7 0.6 0.6 0.6 0.7
SD 0.9 0.8 0.8 0.7 0.6 0.6 0.5 0.6 0.9 0.8 0.7 0.9 0.6 0.5
IC 95% 0.6 1.1 1.0 1.0 0.6 0.6 0.7 0.5 0.4 0.5 0.4 0.3 0.4 0.2
1.1 1.5 1.4 1.4 0.9 0.9 0.5 0.8 0.9 0.9 0.8 0.9 0.8 0.7
Test T
RME vs LEAF 0.001*** 0.020** 0.000*** 0.000*** 0.000*** 0.000*** 0.000*** 0.000*** 0.15 0.08 0.07 0.55 0.36 0.08
Cohen effect size 1.7 L 0.8 L 1.4 L 1.8 L 1.9 L 1.7 L 1.1 L 0.9 L
Note: M=morning questionnaire registration, E=evening questionnaire registration. Cohen effect size: S indicates small clinical significance; M, medium clinical significance; L, large clinical significance.
*P=.05;
**P=.01;
***P=.001.
|
7
UGOLINI et aL.
To our knowledge, no other study investigated the pain in-
tensity and discomfort during maxillary arch expansion with
a memory leaf spring, and based on the present results, it can
be postulated that statistically significant differences in the
perception of pain found during the active phase of expan-
sion between RME and LEAF group were due to the different
biomechanical work carried out by the screws, which release
the force generated by activation with different patterns, as
reviewed by Romanyk et al.26
The LEAF screw is designed to compress a double nick-
el-titanium leaf spring that recovers its original shape during
deactivation, resulting in a calibrated expansion of the upper
arch.21,22 This slow and continuous activation significantly re-
duces the mechanical forces transmitted to the bone and sutural
complex, consequently decreasing the inflammatory response
and maintaining tissue integrity during repositioning and re-
modelling of the midpalatal suture, as postulated by Arndt.29
It has been observed that the forces generated by the
jackscrews, which can reach up to 10 pounds per turn,13,14
produced a series of reactions characterized by tissue dis-
placement, deformation, and development of cellular stress in
the palatine suture area with the formation of exudates, fibro-
blasts death, collagen fibres disruption, and acute inflamma-
tion.30 Human and animal studies have shown that following
a rapid expansion of the palatal suture, a disorganized and
highly vascularized connective inflammatory tissue is cre-
ated, which acts as the main receptor of the pain perceived
during the expansion.14,15,17 The transmission of the slow
and continuous force generated by the nickel-titanium screw
inhibits the establishment of these inflammatory processes
with the clinical effect of a limited and negligible perception
of pain during appliance activation, unlike the level of pain
reported with the traditional screw expander. To corroborate
this hypothesis, a significantly higher risk of suffering from
pain and tension in the anterior and in the anchored/posterior
teeth was found in the RME group only. The main limitation
of the present study is that the skeletal effects of the Leaf
Expander on the midpalatal suture have not yet been clari-
fied, even if some promising results were recently published
as reported by Manzella et al31 which found a mild sutural
disruption after Leaf Expander treatment. Anyway, our anal-
ysis did not evaluate the skeletal effects of the appliances and
further carefully designed studies taking into account the su-
tural opening are necessary to support this hypothesis. So,
based on our results, we can conclude the Leaf Expander is
an effective pain-free and compliance-free alternative treat-
ment for patients with maxillary arch constriction.
5
|
CONCLUSION
Pain suffered during maxillary arch expansion is influ-
enced by the choice of screw and activation protocol, and
the use of continuous force through the nickel-titanium
spring allows avoiding the worst levels of pain in the first
7days of activation. Leaf Expander proved itself an effec-
tive and efficient expansion appliance in the prevention of
pain.
CONFLICT OF INTEREST
Alessandro Ugolini, Gianguido Cossellu, Marco Farronato,
Armando Silvestrini-Biavati, and Valentina Lanteri declare
that they have no conflict of interest.
AUTHORS' CONTRIBUTIONS
AU contributed to the design of the study, analysis, and in-
terpretation of data and drafted the manuscript; GC contrib-
uted to acquisition and interpretation of data and critically
revised the manuscript; MF contributed to interpretation of
data; VL contributed to acquisition and interpretation of data;
and ASB contributed to conception and design of the study
and critically revised the manuscript.
ORCID
Alessandro Ugolini https://orcid.
org/0000-0002-2062-6014
Gianguido Cossellu https://orcid.
org/0000-0001-6442-5591
Marco Farronato https://orcid.
org/0000-0002-6209-9873
Valentina Lanteri https://orcid.
org/0000-0003-2191-8673
REFERENCES
1. Bucci R, D'Antò V, Rongo R, Valletta R, Martina R, Michelotti
A. Dental and skeletal effects of palatal expansion techniques: a
systematic review of the current evidence from systematic reviews
and meta-analyses. J Oral Rehabil. 2016;43:543-564.
2. Agostino P, Ugolini A, Signori A, Silvestrini-Biavati A, Harrison
JE, Riley P. Orthodontic treatment for posterior crossbites.
Cochrane Database Syst Rev. 2014;(8):CD000979. https ://doi.
org/10.1002/14651 858.CD000 979.pub2
3. Baccetti T, Franchi L, Cameron CG, McNamara JA Jr.
Treatment timing for rapid maxillary expansion. Angle Orthod.
2001;71:343-350.
4. Ugolini A, Cerruto C, Di Vece L, et al. Dental arch response to
Haas-type rapid maxillary expansion anchored to deciduous vs per-
manent molars: a multicentric randomized controlled trial. Angle
Orthod. 2015;85:570-576.
5. Needleman HL, Hoang CD, Allred E, Hertzberg J, Berde C.
Reports of pain by children undergoing rapid palatal expansion.
Pediatr Dent. 2000;22:221-226.
6. Schuster G, Borel-Scherf I, Schopf PM. Frequency of and complica-
tions in the use of RPE appliances-results of a survey in the Federal
State of Hesse. Germany. J Orofac Orthop. 2005;66:148-161.
7. De Felippe NL, Da Silveira AC, Viana G, Smith B. Influence of
palatal expanders on oral comfort, speech, and mastication. Am J
Orthod Dentofacial Orthop. 2010;137:48-53.
8
|
UGOLINI et aL.
8. Halicioglu K, Kiki A, Yavuz I. Subjective symptoms of RME pa-
tients treated with three different screw activation protocols: a ran-
domized clinical trial. Aust Orthod J. 2012;28:225-231.
9. Baldini A, Nota A, Santariello C, Assi V, Ballanti F, Cozza P.
Influence of activation protocol on perceived pain during rapid
maxillary expansion. Angle Orthod. 2015;85:1015-1020.
10. Bucci R, Montanaro D, Rongo R, Valletta R, Michelotti A, D'Antò
V. Effects of maxillary expansion on the upper airways: evidence
from systematic reviews and meta-analyses. J Oral Rehabil.
2019;46:377-387.
11. Cossellu G, Farronato G, Nicotera O, Biagi R. Transverse maxil-
lary deficit and its influence on the cervical vertebrae maturation
index. Eur J Paediatr Dent. 2016;17:147-150.
12. Lione R, Franchi L, Cozza P. Does rapid maxillary expan-
sion induce adverse effects in growing subjects? Angle Orthod.
2013;83:172-182.
13. Mason C, Porter SR, Madland G, Parry J. Early management of
dental pain in children and adolescents. J Dent. 1997;25:31-34.
14. Isaacson RJ, Ingram AH. Forces produced by rapid maxillary ex-
pansion. Angle Ortho. 1964;34:261-270.
15. Isaacson RJ, Wood JL, Ingram AH. Forces produced by rapid max-
illary expansion. Angle Ortho. 1964;34:256-260.
16. Silvestrini-Biavati A, Angiero F, Gambino A, Ugolini A. Do
changes in spheno-occipital synchondrosis after rapid maxillary
expansion affect the maxillomandibular complex? Eur J Paediatr
Dent. 2013;14(1):63-67.
17. Cleall JF, Bayne DJ, Posen JM, Subtenly JD. Expansion of the
mid-palatal suture in the monkey. Angle Orthod. 1965;35:23-35.
18. Joviliano P, Junqueira AA, Stabile AC, Leite-Panissi CR, Rocha
MJ. Rapid maxillary expansion causes neuronal activation in brain
structures of rats. Brain Res Bull. 2008;76:396-401.
19. Gecgelen M, Aksoy A, Kirdemir P, et al. Evaluation of stress and
pain during rapid maxillary expansion treatments. J Oral Rehabil.
2012;39:767-775.
20. Feldmann I, Bazargani F. Pain and discomfort during the first
week of rapid maxillary expansion (RME) using two different
RME appliances: a randomized controlled trial. Angle Orthod.
2017;87:391-396.
21. Cossellu G, Lanteri V, Lione R, et al. Efficacy of ketoprofen lysine
salt and paracetamol/acetaminophen to reduce pain during rapid
maxillary expansion: a randomized controlled clinical trial. Int J
Paediatr Dent. 2019;29:58-65.
22. Lanteri C, Beretta M, Lanteri V, Gianolio A, Cherchi C, Franchi
L. The leaf expander for non-compliance treatment in the mixed
dentition. J Clin Orthod. 2016;50:552-560.
23. Lanteri V, Gianolio A, Gualandi G, Beretta M. Maxillary tridi-
mensional changes after slow expansion with leaf expander in a
sample of growing patients: a pilot study. Eur J Paediatr Dent.
2018;19:29-34.
24. Wong DL, Baker CM. Pain in children: comparison of assessment
scales. Okla Nurse. 1988;33:8.
25. Cohen J. A power primer. Psychol Bull. 1992;112:155-159.
26. Romanyk DL, Lagravere MO, Toogood RW, Major PW, Carey
JP. Review of maxillary expansion appliance activation methods:
engineering and clinical perspectives. J Dent Biomech. 2010;1-7.
https ://doi.org/10.4061/2010/496906
27. Nota A, Tecco S, Caruso S, Severino M, Gatto R, Baldini A.
Analysis of errors in following the rapid maxillary expansion
activation protocol: an observational study. Eur J Paediatr Dent.
2019;20:116-118.
28. Bartzela TN, Senn C, Wichelhaus A. Load-deflection charac-
teristics of superelastic nickel-titanium wires. Angle Orthod.
2007;77:991-998.
29. Arndt WV. Nickel titanium palatal expander. J Clin Orthod.
1993;27:129-137.
30. Mao JJ. Mechanobiology of craniofacial sutures. J Dent Res.
2002;81:810-816.
31. Manzella K, Franchi L, Al-Jewair T. Correction of maxillary trans-
verse deficiency in growing patients with permanent dentitions. J
Clin Orthod. 2018;52:148-156.
How to cite this article: Ugolini A, Cossellu G,
Farronato M, Silvestrini-Biavati A, Lanteri V. A
multicenter, prospective, randomized trial of pain and
discomfort during maxillary expansion: Leaf expander
versus hyrax expander. Int J Paediatr Dent.
2020;00:1–8. https ://doi.org/10.1111/ipd.12612
... 7 However, it is common for this intervention to be associated with reports of pain. 5,13,20 Given this context, the objective of this scoping review is to evaluate pain perception during rapid maxillary expansion, considering factors such as age, sex and type of expander. ...
... 1,6,8,11,13,14 Studies indicate that in the initial stages of ERM, there is a formation of highly vascularized and disorganized in ammatory connective tissue, playing a central role in the perception of pain during the expansion process. 7,11 In subsequent activations, a reduction in suture separation is observed, explaining the decrease in pain perception in children, as evidenced by previous studies 7, 10,14,20 Furthermore, the reduction in painful sensation may be associated the patient's progressive adaptation to the procedure, resulting in less restlessness and anxiety regarding the manipulation of the expander. 9.13 The consumption of analgesics in some studies may have impacted participants' perception of pain. ...
... 9.13 The consumption of analgesics in some studies may have impacted participants' perception of pain. 8, 20 For example, in the study by Needleman et al. (2000), 12 98% of patients reported pain, and 48% consumed analgesics. In contrast, in the study by Hansson et al. (2023), 11 the consumption of analgesics was low and did not differ signi cantly between the groups. ...
Preprint
Full-text available
Introduction: Rapid maxillary expansion (ERM) is a procedure to correct orthodontic and orthopedic problems. Objective: The purpose of this scoping review was to evaluate the pain reported by children and adolescents undergoing RME, in relation to age, sex and type of expander. Methodology: The research was carried out in electronic databases, including PubMed, Scopus, Web of Science, Scielo and Lilacs, in addition to gray literature. This investigation involved terms relevant to the population (children and adolescents), the concept (pain perception) and the context (ERM). Sequential screenings were carried out based on pre-established eligibility criteria. Results: Fifteen works were included in this study. The prevalence of pain reports was notable, particularly in the first 4 to 6 days following expander activation. Conclusions: The ERM technique can cause mild to severe pain, which tends to decrease after the first few days of intervention. Perceived pain does not seem to be influenced by age and sex, but by the type of expander. Under appropriate pain management and expert guidance, this technique can be performed safely and effectively.
... RME produce an immediate mid-palatal suture separation using heavy and intermittent forces for a short time which produce a significant effect on maxillary transverse dimensions [15], whilst, in contrast, SME is done using intermittent and lower forces for a longer period of time [10]. On the contrary, appliances with a Ni-Ti elastic modulus produce a slow maxillary expansion using low and constant forces and are more comfortable for young patients and do not require parental collaboration [16]. ...
... Recently, a new slow palatal expander with Ni-Ti leaf springs (Leaf Expander®, Leone, Italia) as an active part has been introduced [17]. The design of the device is similar to a Hyrax expander, the difference being that the Leaf Expander has nickel titanium leaf springs through which lower, more steady and calibrated forces are produced to obtain the palatal expansion [16]. The main objective of the appliance is to obtain a compliance-independent SME with an appropriate force system [18]. ...
... The results of the present study disagree with a randomized controlled trial performed on bidimensional radiographs and digital models by Paoloni et al. [20] where a significantly greater increase in the deciduous intercanine width (53-63) using RME was found. The present findings are also in contrast with those reported by Cossellu et al. [45] where a statistically significant difference in deciduous intercanine width (53-63) between Leaf Expander and RME were reported, finding significantly greater results in the Leaf Expander group, whereas the increase in maxillary intermolar width (16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26) was statistically significantly greater in the RME group. In this study no statistically significant difference was found between the two expansion protocols for the same variables. ...
Article
Full-text available
Background The aim of the present study was twofold:(1) three-dimensionally evaluate the quantitative skeletal and dentoalveolar changes after Ni–Ti leaf spring expander (leaf expander) and rapid maxillary expansion (RME) in mixed dentition patients;(2) analyze the modifications of the buccal alveolar bone plate of the maxillary first permanent molars. Methods Patients who underwent CBCT scans before and after maxillary expansion were randomly selected from the records archived at the Department of Biomedical Surgical and Dental Sciences, University of Milan, Italy. Inclusion criteria were the following: no systemic disease or syndromes; maxillary transverse deficiencies (difference between the upper intermolar width and the lower intermolar width of at least 3 mm and/or clinical need based on radiographic evaluation), early mixed dentition with ages between 7 to 10 years old; cervical vertebra maturation stage (CVMS) 1 or 2; no pathologic periodontal status; skeletal class I or II; maxillary expander cemented on the upper second deciduous molars. Exclusion criteria were the following: patients with pubertal or post-pubertal stage of development (CVMS 3–6); late deciduous or late mixed dentition, impossibility to use the second primary molar as anchorage; skeletal class III malocclusion; craniofacial syndromes; patients unable to be followed during the treatment period. Twenty-three patients treated with Leaf Expander, 11 males (mean age 7.8 ± 0.6 years) and 12 females (mean age 8.1 ± 0.8 years), met the inclusion criteria and constituted the case group. Twenty-four (control group) treated with conventional RME, 12 males (mean age 8.4 ± 0.9 years) and 12 females (mean age 8.1 ± 0.7 years). The paired-sample T test was used for intra-group comparison to evaluate the difference between before (T1) and after (T2) maxillary expansion. Independent sample t-test was computed to perform between groups comparison of the skeletal, dentoalveolar, and periodontal changes. Results The Leaf Expander and RME group showed a significant increase between T1 and T2 for most of the skeletal and dentoalveolar variables. Concerning the skeletal variables only the RME demonstrated a significant increase at the level of the posterior nasal (PNW) and apical base width (PABW) and maxillary mid-alveolar width (MMW). Despite this, when compare with the Leaf Expander, the RME group exhibited a statistically larger width increase for only two skeletal parameters: PNW (p = 0.03) and MMW (p = 0.02). No significant changes at the periodontal level were found in either group. Conclusions According to the current research, the authors confirm the effectiveness of the Leaf Expander and RME to produce similar skeletal and dentoalveolar effects in mixed dentition subjects. Moreover, the devices anchored to deciduous teeth did not reduce the thickness and height of the buccal bone at the level of the maxillary permanent first molars in either of the two groups.
... Several types of appliances are used for ME. These include the Hyrax appliance (de Araújo et al. 2021), Haas appliance (Haas 1961), mini hyrax appliance (Silveira et al. 2021), hybrid hyrax appliance (Feldmann and Bazargani 2017), computer-guided skeletal RME appliance (Altieri and Cassetta 2020), and leaf expander appliance (Ugolini et al. 2020a). ...
... A total of 18 articles were evaluated by full text, and 12 were excluded based on the imposed eligibility criteria (Appendix). Six RCTs (Altieri and Cassetta 2020; de Araújo et al. 2021;Feldmann and Bazargani 2017;Nieri et al. 2021;Silveira et al. 2021;Ugolini et al. 2020a) were included in the present systematic review and processed for data extraction (Fig. 1). ...
... All RCTs included both male and female patients. Three RCTs reported no drop-outs for the patients (Altieri and Cassetta 2020;de Araújo et al. 2021;Nieri et al. 2021), while three RCTs reported that there were drop-outs of patients (Feldmann and Bazargani 2017;Silveira et al. 2021;Ugolini et al. 2020a). The reasons for dropping out were listed as: patient not completing the questionnaire, not showing up at the follow-up appointments, a lack of collaboration, or appliance getting damaged. ...
Article
Purpose: To evaluate self-perceived pain levels in the Hyrax compared to other types of maxillary expansion (ME) appliances in growing patients. Methods: An unrestricted search of indexed databases and manual searching were performed up to October 2022. Randomized controlled trials (RCTs) comparing the Hyrax appliance with other ME appliances were included. Data screening, extraction, and Risk of Bias (RoB) assessment with the Cochrane tool were performed by two authors. Results: Six RCTs were included. The number of participants in the included RCTs ranged between 34 to 114 and included both male and female growing patients. Various tools were used to measure self-perceived pain including the Graphic Rating Scale for Pain, the Wong-Baker Faces Pain Scale, the Numerical Rating Scale, the visual analogue scale, and a questionnaire. One RCT reported that pain intensity in patients treated with the Hyrax was higher than in the Haas appliance, with a statistically significant difference limited to the first day. Two RCTs reported that pain intensity in patients treated with the Leaf expander was lower than in the Hyrax during the first 7 days of treatment. Two RCTs reported no significant differences in pain intensity between the Hyrax and other ME appliances. One RCT reported that pain intensity in patients using the computer-guided skeletal ME appliance was higher than in the Hyrax appliance at the first day after expansion. Four RCTs had a high RoB, and two RCTs had a moderate RoB. Conclusions: Within the limitations of the present systematic review and based on the currently available evidence, it is challenging and inconclusive to identify the best maxillary expansion appliances, regarding pain levels for growing patients.
... 12,13 Additionally, compared to conventional RME, the Leaf Expander typically results in lower levels of pain during the initial days following its application. 14 Regarding the spontaneous distorotation of first permanent molars following different modalities of maxillary expansion, the literature is currently notably lacking. The only study available to date is conducted by Cerruto et al., 15 demonstrating that, following an interceptive phase of RME, there is a spontaneous distorotation of upper first permanent molars. ...
Article
Full-text available
Objective The aim of this randomized controlled trial (RCT) was to evaluate the spontaneous distorotation of upper first permanent molars and the transverse dentoalveolar changes on digital casts in growing patients following maxillary expansion treatment using either the Leaf Expander® or the rapid maxillary expander (RME), both anchored to the deciduous second molar. Trial Design and Setting This study was a two‐arm, parallel‐assignment, RCT with a dual‐centre design conducted at two teaching hospitals in Italy. Participants Inclusion criteria included maxillary transverse deficiency, prepubertal development stage (cervical vertebra maturation stage [CVMS] 1–2) and early mixed dentition with fully erupted upper first permanent molars. Exclusion criteria were systemic diseases or syndromes, CVMS 3–6, agenesis of upper second premolars, unavailability of the second deciduous molar for anchorage and Class III malocclusion. Randomization Patients were randomly assigned to the Leaf Expander® or RME group using a computer‐generated randomization list created by a central randomization centre. Randomization was conducted immediately before the start of treatment. Intervention The intervention involved treatment with either the Leaf Expander® or the RME. Both devices were anchored to the second deciduous molars. Following randomization, patients were further categorized based on the presence of no crossbite, unilateral crossbite or bilateral crossbite. Main Outcome Measure The primary outcome measure was the distorotation of the upper first molar (U6). Secondary outcomes included measurements of interdental linear dimensions, specifically upper inter‐canine width (53–63), upper inter‐molar width (MV16–MV26) and upper inter‐deciduous second molar width (55–65). Blinding The examiner analysing the digital casts was blinded to the treatment groups to prevent detection bias and ensure objective assessment. However, due to the nature of the intervention, blinding was not feasible for the patients and clinicians involved in administering the treatment. Results A total of 150 patients were enrolled and randomly assigned to two groups: 75 to the Leaf Expander® group and 75 to the RME group. Recruitment started in November 2021 and was completed in November 2022. At the time of analysis, the trial was complete with no ongoing follow‐ups. ANOVA tests revealed no significant differences between the three subgroups (no‐cross, unilateral‐cross and bilateral‐cross) within both the Leaf Expander® and RME groups at T0. The Leaf Expander® demonstrated significantly greater distorotation in the unilateral crossbite subgroup compared to the RME ( p = .014). In terms of total molar distorotation, the Leaf Expander® appliance showed a significantly greater effect (12.66°) compared with conventional RME (7.83°). Linear regression analysis demonstrated a significant correlation between the extent of expansion and the degree of molar rotation. Conclusions Maxillary expansion resulted in significant spontaneous molar distorotation when the appliance was bonded to the second deciduous molars. The Leaf Expander® exhibited significantly greater molar distorotation compared with conventional RME. The degree of molar distorotation was correlated with the extent of expansion obtained on the second deciduous molar. Trial Registration The trial was registered at ClinicalTrials.gov (ID: NCT05135962).
... Moreover, the pain perceived during the expansion seems to be lower, because the design of the leaf screw allows a slow and continuous activation, reducing the forces transmitted to the sutural complex and the consequent inflammatory process. 14,15 Previous studies have demonstrated that leaf expander creates less discomfort for the patient and less pain during the first days of activation, and it allows also a better oral hygiene. 14 Furthermore, many recent studies have demonstrated that RME and leaf expander result in similar clinical outcomes. ...
Article
Full-text available
Objective The aim of this study was to evaluate changes in shape of the palatal vault after maxillary expansion with hyrax expander (HE) and leaf expander (LE), using 3D Geometric Morphometric Analysis. Setting and Sample Population Overall, 250 patients (110 M, 140 F) with maxillary transverse deficiency were selected for this study. In this study, 127 subjects were treated with HE, 123 with LE. Materials and Methods Digital dental models were obtained pre‐treatment (T0) and after 12 months from the cementation of the device (T1) and processed by means of a digital scanner. Linear and morphometric analyses were conducted to determine the effects of each appliance on dental measurements and palatal shape, and a multiple linear regression was performed to analyse the influence of anchorage and appliance type on final shape. Results Morphometric analysis showed that there was a lowering of the palatal vault in the HE group, while in the LE group it remained unchanged: the difference in palatal shape at time T0 and T1 was statistically significant in both treatments (HE vs. LE). In the HE group, the change in shape also included the upper part of the palatal vault in the vertical dimension, while in the LE group the change in shape interested mainly palatal shelves and the lower portion of the palate. Conclusions Both LE and HE produce clinically significant changes in the morphology of the palatal vault.
... Alternatively, it can be achieved with calibrated and continuous forces that promote maxillary expansion using a Ni-Ti leaf springs palatal expander (Leaf Expander) that has a small-sized body and is similar to a conventional Hyrax expander [22][23][24]. Several studies have endorsed the utilization of devices that facilitate gradual expansion to minimize unwanted side effects [25][26][27] and enhance long-term stability following expansion [28,29]. ...
Article
Full-text available
(1) Background: This study aims to investigate, within a controlled laboratory environment, the magnitude of the transversal load and the force decay over time produced by clear aligners in comparison to a Rapid Palatal Expander (RPE). (2) Methods: Resin models of a dental maxillary arch, additively manufactured from an intraoral scan, were inserted in a testing machine with uniaxial load cells to measure the force trend over time expressed by RPE and clear aligners. The mechanical load was recorded during a certain timeframe for both appliances. (3) Results: The force expressed by the RPE ranged from 30 to 50 N for each activation, decreasing with a nonlinear pattern over time. The force expressed by the clear aligner ranged from 3 to 5 N, decreasing with a linear pattern over time. In contrast, the force generated by the clear aligner fell within the range of 3 to 5 N, showing a linear reduction in force magnitude over the observed period of time. (4) Conclusions: The RPE exerted a force magnitude approximately ten times greater than that generated by clear aligners. Nevertheless, it is essential to acknowledge that the oral environment can significantly influence these results. These limitations underscore the need for caution when applying these findings to clinical settings.
... On the contrary, slow maxillary expansion (SME) typically utilizes continuous low-force systems applied over a longer period, and it is achieved through removable or fixed expanders (e.g., Quad Helix appliance, removable plates, RME devices with slow activation protocols) [5,7]. More recently, an increasing interest of researchers addresses toward fixed devices that are equipped with a screw whose activation generates the compression of two or more nickel titanium leaf springs that recover their original shape during deactivation (Leaf expander) [8][9][10][11]. ...
Article
Full-text available
Objective To compare the effects on facial soft tissues produced by maxillary expansion generated by rapid maxillary expansion (RME) versus slow maxillary expansion (SME). Materials and methods Patients in the mixed dentition were included with a transverse discrepancy between the two arches of at least 3 mm. A conventional RME screw was compared to a new expansion screw (Leaf expander) designed to produce SME. Both screws were incorporated in a fixed expander. The primary outcome was the difference of the facial tissue changes in the nasal area measured on facial 3D images captured immediately before application of the expander (T0) and after one year of retention, immediately after the expander removal (T1). Secondary outcomes were soft tissue changes of other facial regions (mouth, lips, and chin). Analysis of covariance was used for statistical analysis. Results Fourteen patients were allocated to the RME group, and 14 patients were allocated to the SME group. There were no dropouts. Nasal width change showed a difference between the two groups (1.3 mm greater in the RME group, 95% CI from 0.4 to 2.2, P = 0.005). Also, intercanthal width showed a difference between treatments (0.7 mm greater in the RME group, 95% CI from 0.0 to 1.3, P = 0.044). Nasal columella width, mouth width, nasal tip angle, upper lip angle, and lower lip angle did not show any statistically significant differences. The Y -axis (anterior–posterior) components of the nasal landmark showed a statistically significant difference between the two groups (0.5 mm of forward displacement greater in the RME group, 95% CI from 0.0 to 1.2, P = 0.040). Also, Z -axis (superior-inferior) components of the lower lip landmark was statistically significant (0.9 mm of downward displacement in favor of the RME group, 95% CI from 0.1 to 1.7, P = 0.027). All the other comparisons of the three-dimensional assessments were not statistically significant. Conclusions RME produced significant facial soft tissue changes when compared to SME. RME induced greater increases in both nasal and intercanthal widths (1.3 mm and 0.7 mm, respectively). These findings, though statistically significant, probably are not clinically relevant. Trial registration ISRCTN, ISRCTN18263886. Registered 8 November 2016, https://www.isrctn.com/ISRCTN18263886?q=Franchi&filters=&sort=&offset=2&totalResults=2&page=1&pageSize=10
... For the analysis of pain intensity, the Wong-Baker scale was used, during the first week of apparatus placement. As shown in the table, it can be seen that subjects treated with leaf expander experienced less pain both from the point of view of intensity and duration than subjects treated with standard Hyrax [20]. ...
Article
Full-text available
Unlabelled: Maxillary bone contraction is caused by genetics or ambiental factors and is often accompanied by dental crowding, with the possibility of canine inclusion, crossbite, class II and III malocclusion, temporomandibular joint disorder, and obstructive sleep apnea (OSAS). Transverse maxillary deficits, in which the maxillary growth is unusually modest, are frequently treated with maxillary expansion. The purpose of this study is to compare the dental and skeletal effects of different types of expanders, particularly the Leaf Expander, rapid and slow dental-anchored or skeletal-anchored maxillary expanders. Methods: We chose studies that compared effects determined by palatal expansion using a rapid palatal expander, expander on palatal screws, and leaf expander. Results: Reports assessed for eligibility are 26 and the reports excluded were 11. A final number of 15 studies were included in the review for qualitative analysis. Conclusions: Clinically and radiographically, the outcomes are similar to those obtained with RME and SME appliances; Therefore, it might be a useful treatment choice as an alternative to RME/SME equipment in cases of poor patient compliance or specific situations. Finally, all of the devices studied produce meaningful skeletal growth of the palate. The use of skeletally anchored devices does, without a doubt, promote larger and more successful growth in adolescent patients.
... I pazienti partecipanti allo studio di ricerca osservazionale sono stati esaminati mensilmente. Durante ogni controllo clinico è stata verificata anche l'igiene orale (segni di placca) [26,27] così come le condizioni del tessuto parodontale e anche la compliance del paziente (disagio) attraverso l'utilizzo di appositi questionari [28,29] . dall'ipertrofia adenoidea [30][31][32] . ...
Article
Secondo alcuni studi, dal confronto tra espansione rapida del palato (RME) ed espansione con espansore a balestre in Ni-Ti ed espansione mascellare lenta (SME) emerge una maggiore efficacia della prima riguardo al dia-metro intercanino superiore e all'aumento della pervietà delle vie aeree nasali. Al fine di migliorare l'efficacia correttiva nei soggetti respiratori orali o con marcato affollamento mascellare nasce il protocollo di attivazione two in one. In altri termini l'espansore a balestre in Ni-Ti può essere adoperato in moda-lità ibrida, anche per ottenere l'espansione rapida del palato, modificandone l'attivazione e quindi le caratteristiche biomeccaniche. L'obiettivo del presente studio è quello di analizzare su modelli digi-tali i cambiamenti a carico del mascellare superiore dopo terapia con espansore a balestre in Ni-Ti utilizzando un protocollo di attivazione ibrida in due fasi (RME e SME).
Article
Full-text available
Aim The aim of this study is to analyse the correspondence between the reported number of activations and the number of prescribed activations. Materials and Methods A total of 114 subjects with constricted maxillary arches (58 males, 56 females; mean age 10.26 ± 1.92 years) were enrolled in the study. The subjects underwent RME and all the parents were provided with a screw activations report form in order to remind them the number of prescribed activations. At the removal of the expander, the screw was turned back in order to count the effective number of activations applied. Results In 46 cases, out of a total of 114 patients, an involuntary error during the activation procedure was presumably made. A slight statistically significant correlation between the number of activations prescribed, and the number of incorrect activations was found. The errors consisted in added or missed activations, compared to the prescribed number but more frequently in missed activations with statistical significance. Conclusions Errors in following the rapid palatal expansion activation protocol are not uncommon. These errors could consist in missed or added activations to the number prescribed by the orthodontist, more often in missed activations.
Article
Full-text available
Objectives: To evaluate and compare perceived pain intensity, discomfort, and jaw function impairment during the first week with tooth-borne or tooth-bone-borne rapid maxillary expansion (RME) appliances. Materials and methods: Fifty-four patients (28 girls and 26 boys) with a mean age of 9.8 years (SD 1.28 years) were randomized into two groups. Group A received a conventional hyrax appliance and group B a hybrid hyrax appliance anchored on mini-implants in the anterior palate. Questionnaires were used to assess pain intensity, discomfort, analgesic consumption, and jaw function impairment on the first and fourth days after RME appliance insertion. Results: Fifty patients answered both questionnaires. Overall median pain on the first day in treatment was 13.0 (range 0-82) and 3.5 (0-78) for groups A and B, respectively, with no significant differences in pain, discomfort, analgesic consumption, or functional jaw impairment between groups. Overall median pain on the fourth day was 9.0 (0-90) and 2.0 (0-71) for groups A and B, respectively, with no significant differences between groups. There were also no significant differences in pain levels within group A, while group B scored significantly lower concerning pain from molars and incisors and tensions from the jaw on day 4 than on the first day in treatment. There was a significant positive correlation between age and pain and discomfort on the fourth day in treatment. No correlations were found between sex and pain and discomfort, analgesic consumption, and jaw function impairment. Conclusions: Both tooth-borne and tooth-bone-borne RME were generally well tolerated by the patients during the first week of treatment.
Article
Full-text available
Aim: The aim of this study is to evaluate whether a transverse maxillary deficit can cause an alteration of vertebral development and therefore of the skeletal maturation comparing the cervical maturation stages index with the hand-wrist index. Materials and methods: For the study were selected 200 patients aged 7 - 14 years, equally distributed by gender and divided into 100 study subjects with maxillary deficit and 100 controls without maxillary deficit. The skeletal maturation index (SM according to Fishman) was evaluated and compared with the hand-wrist x-rays and the cervical vertebrae maturation (CVM according to Hassel and Farmann). Results: Forty-one per cent of the subjects in the test group show a discrepancy between CVM and SM. Among these 73% (30 subjects) present an advanced stage of CVM compared with the corresponding SM. Only 16% of the subjects in the control group show a discrepancy between CVM and SM. Among these 69% (11 subjects) appear in an advanced CVM stage. Conclusion: The analysis of the CVM stage in subjects with transverse maxillary deficit appears to be altered compared with the SM identified through a hand-wrist x-ray. In the case of individuals with transverse maxillary deficit it is advisable to use also a hand- wrist x-ray, thus not relying only on CVM for the evaluation of the skeletal growth stages.
Article
Background Constricted maxilla is frequently associated with reduced nasal airway dimensions. Wheatear skeletal maxillary expansion (ME) is effective on the dimension of the upper airways is still a debated issue. Objectives This overview aimed to report the evidence provided by systematic reviews (SRs) on the effect of ME on the upper airways, and to assess the methodological quality of the included SRs. Methods Six electronic databases have been explored up to November 2017. After title and abstract screening, SRs addressing the effects of fixed palatal expanders on the dimension and function of the nasal airways were included. The methodological quality of the included SRs was assessed using the updated version of A Measurement Tool to Assess Systematic Review (AMSTAR‐2). Results Eight SRs were included. The methodological quality of most of the included SRs ranged between low and critically low. One SR was rated of high quality. A significant increase of nasal linear dimensions was reported both in the short‐ and long‐term, but supported by low/critically low quality SRs. The significant increase of nasal cavity volume was the only outcome supported by a high quality SR. Controversial results were found with regards to nasal function. Conclusion Whenever a constricted maxilla is present general dentists, pediatricians and ENTs should be familiar with the potential improvement provided by ME. However, due to the low/critically low quality of SRs supporting these results, ME cannot be indicated only for upper airways enhancement, but should be supported by an orthodontic indication. This article is protected by copyright. All rights reserved.
Article
Background Rapid maxillary expansion (RME) is an orthopaedic procedure indicated for a wide variety of clinical conditions. Aim The aim of the study was to compare the effects of ketoprofen lysine salt (KLS) vs paracetamol/acetaminophen (P) on pain perception during RME. Design One hundred and fifty‐one subjects (mean age 8.6 year) were enrolled in this prospective controlled clinical trial according to inclusion criteria: prepuberal stage of development, negative posterior transverse interarch discrepancy, non‐concurrent use of other drugs. First phase: n.40 allocated to Group 1 used 40 mg of KLS, n.40 to Group 2 used 250 mg of P, n.36 to Group 3 as control group. Second phase: n.35 allocated to Group 4 used 40 mg ketoprofen lysine salt once a day for the first 3 days of activation. Pain experience was reported on a numeric rating scale (0‐4) and a 100‐mm visual analogue scale. Pain perception was tested with the Mann‐Whitney test (P < 0.05). Results Pain perception was higher during the first 3 days of activation and it was described as mild to moderate. Group 1 experienced significantly less pain during the fourth, fifth, and sixth day (P < 0.05) compared with Group 2. Patients of the Group 4 reported significantly lower pain during the whole period of RME activation (P < 0.05). Conclusions The perceived higher pain was reported during the second and third day of expansion. The analgesic effect of KLS is more effective than P during the fourth, fifth, and sixth day. The use of KLS during the first 3 days of activation seems to be able reducing pain during the whole active phase.
Article
Aim: The aim of this study is to evaluate the dento-alveolar effects of slow maxillary expansion using the Leaf Expander in a sample of growing patients with maxillary transverse deficiency, unilateral cross bite and mandibular shift. Materials and methods: The study included 10 patients, 3 male and 7 female (mean age 7.5 + 7 months), treated with Leaf Expander anchored on the upper deciduous teeth. Digital models were obtained by a lab scan of the pvs impressions at the beginning of the therapy (T1) and at the removal of the palatal expander (T2). Five parameters were measured: 1) the distance between the first upper permanent molars; 2) the distance between the upper second deciduous molars; 3) the distance between the upper canine cusps 4) the distance between the first lower permanent molars; 5) the distance of the lower canine cusps. Results: In all patients complete correction of posterior crossbite was achieved on average in 4 months, with a spontaneous expansion of the upper first permanent molars. Significant increases in the dento-alveolar transversal diameters were obtained. Increases were also observed in the anterior mandibular arch diameter (+ 1 mm). Conclusions: These findings suggest that slow maxillary expansion using Leaf Expander appliance could be a reasonable alternative to conventional maxillary expansion therapy in the early mixed dentition.
Article
Transverse discrepancy due to a reduced palatal dimension, usually accompanied by upperarch crowding and crossbite, is one of the most common problems seen in orthodontics.1-2 Various devices for orthopedic maxillary expansion have been described, with the common objective of minimizing dental effects and maximizing skeletal effects.3 In the early mixed dentition, a transverse discrepancy can be effectively solved by anchoring a fixed expansion device such as a rapid palatal expander or Quad Helix* to deciduous teeth,4 thus avoiding undesirable effects on the permanent teeth.1,5,6 Even slow maxillary expansion has been shown to have orthopedic effects in growing patients. 7 In 2013, based on our experience with slow expansion,8 we introduced a new spring-based expander with a leaf-shaped active element. This Leaf Expander** eliminates the need for home activation and simplifies clinical management. The present article describes its use for palatal expansion in the mixed dentition.
Article
The aim was to assess the quality and to summarise the findings of the Systematic Reviews (SRs) and Meta-Analyses (MAs) on the dental and skeletal effects of maxillary expansion. Electronic and manual searches have been independently conducted by two investigators, up to February 2015. SRs and MAs on the dentoalveolar and skeletal effects of fixed expanders were included. The methodological quality was assessed using the AMSTAR (A Measurement Tool to Assess Systematic Reviews). The design of the primary studies included in each SR/MA was assessed with the LRD (Level of Research Design scoring). The evidence for each outcome was rated applying a pre-determined scale. Twelve SRs/MAs were included. The AMSTAR scores ranged from 4 to 10. Two SRs/MAs included only RCTs. The current findings from SRs/MAs support with high evidence a significant increase in the short-term of maxillary dentoalveolar transversal dimensions after Rapid Maxillary Expansion (RME). The same effect is reported with moderate evidence after Slow Maxillary Expansion (SME). However, there is moderate evidence of a non-significant difference between the two expansion modalities concerning the short-term dentoalveolar effects. With both RME and SME, significant increase of skeletal transversal dimension in the short-term is reported, and the skeletal expansion is always smaller than the dentoalveolar. Even though dental relapse to some extent is present, long-term results of the dentoalveolar effects show an increase of the transversal dimension, supported by moderate evidence for RME and low evidence for SME. Skeletal long-term effects are reported only with RME, supported by very low evidence.