2004 - Dra Luciane Menezes

OR/GINAtARTICTE
Rizzollo,
S u s o n oM o r i o D e o n
T hi e s e nG
, uilherme
do Rego,Morcus
ViniciusNeivo N unes
Evoluotionof RopidMqxillory
Exponsionby Meqnsof Spirol
ComputedTomogrqphy
Morchioro,
E r n o nM
i enezes
Menezes, Purpore:Theoim of thispoperis to comporeihe rodiogrophickonsverse
chongesproducedby ropid
Lucione Mecedo moxilloryexponsionwith o modifiedHoos.typeexponderusingconventionql
rodiogrophs
ond spirol
Deportmentof Orthodontics,
PortilicolCotholicUniversiiyof
R i oG r o n d ed o S u l ,
PortoAlegre City,
R i oG r o n d ed o S u l ,
Brozil
computerized
tomogrqphy.
Moteriolsond Methods:A potientreportdescribes
o childoged Z yeorsond 6 monthswho requires
ropidmoxilloryexponsion.
Theexponsion
isossessed
by two methods:
firstly,
rodiogrophs
conventionol
ond secondly,
by meonsof spirolcomputedtomogrophic
imoges.
Conclusion:TheresullsindicotethotoveFexponsion
is o good clinicolprocedr.:re.
Thespirolcomputed tomogrophyshowsthottheintermoxillory
sutureopeningis smollerin the posteriorregionthonthot
observedon the conventlonol
rodiogrophic
imoges.
Keywords: moxilloryokesio,ropidmoxilloryexponsion,
spirolcomputedtomogrophy,
infermoxillory
sulure
(Orthodontics
1: 2O7-21 4, 2OO4l
INTRODUCTION
Submittedfor publicotion
6 Moy 2OO4;
occepfedfor publicotion
28 July20O4.
Reprint reque5ls:
rIoI. ur. (,u nermeInresen,
A v M o d r e B e n v e n u f1o2 8 5 ,
SontoM6nico,
8 8035-000 Florion6polis
SC,
Brozil.
E-moil:guilhiesen@hotmoil
com
Angell{l 860) is creditedwith the firstreporton
r o p i d m o x i l l o r ye x p o n s i o n{ R M E ) .n o w e v e r ,
widespreoduseo[ RMEin orthodontics
shouldbe
moinlyotkibutedto ihe clossicolreportsof Hoos
eopers
{ H o o s1, 9 6 1 , 1 9 6 5 ,19 7 O ,19 8 0 } .T h e s p
hod o significont
impoctdemonstroting
itstheropeuticoctionby meonso[ histologicol
studiesin
onimolsond cepholometric
ond clinicotevotuot i o n si n h u m o n s .
Sincethen,mony clinicolstudieshove been describedond RMEhos becorneo commonlyemployedmethod[or thekeotment
of moxilloryokesiofor childrenthroughorthopoedic
theropy,ond
for odults,by meonsof o surgicollyossisied
opprooch(Adkinset ol, 1990; Bergeret ol, 1998;
d o S i l v oF i l h oe t o l , 1 9 9 1 ;P o g r eel t o l , 1 9 9 2 1 .
Thecreotionof o diqslemobefweenthemoxillory
centrolincisors
isihe moinclinicolevidenceo[the
seporotion
of themoxilloryprocesses
ol theinteF
moxillorysuiure.Thisseporotion
of the moxillory
p r o c e s s edsi s p l o y so t r i o n g u l osr h o p ei n b o t h
frontolond horizontol
plones.Inthelrontolplone,
theexponsionis mr..rch
lorgerbetweenthecentrol
incisors
ond is reducedin thesuperiorospect.The
nosolseplum,
vomerondtheperpendiculor
plotes
of the ethmoidbonesore usuollynol compleiely
seporoted,rotherthey ore keptoltochedto one
of the moxilloryor polotol bones.This lqterol
movementmoy olso offectthe internosol,
zygomotic-moxillory,
nosomoxillory
ond frontonqsql
sutures{Moore, 1997; Wertz, 1920). Similorly,
lhe exoonsion
i n t h e h o r i z o n t ool l o n ei s m u c h
greolerql ihe onieriororeo of the polotethonot
the posterior
oreo,os demonskoled
on moxillory
occlusolrodiogrophs.The posteriorpolotol regionis lesssusceptible
to exponsion
duelo theresistonce
exertedbythepositioning
ofthepyromid
processes
of the polotolbonesinsidethe pterygoid plotesof thesphenoidbonelMoore, I 997;
l o l o r ie t o l , 2 0 0 3 ; V o r d i m o en t o l , 1 9 9 8 ] .
Thecepholomekic
chongesyieldedby RMEhove
been demonsirotedin severolsiudies.Loterol
cephologroms
reveolo temporory
downworddisplocementof the moxilloond moxillorymolors,
207
Rizzol+ael ol, RopidMoxillory Exponsion
with minimumond occosionolmovementof the
moxilloin thesogittol
direction
ldo SilvoFilhoet ol,
1 9 9 1 ;d o S ; l v oF i l h oe t o l , 1 9 9 4 ;K o m o w o keil o l ,
1999;Wedz,19ZO) However,
thesechonges
ore
phenomenon
tronsitionol,
constituling
o momentqry
inducedby thistheropylGoribet ol, 2001).
frontolview,
themoxillory
sepIntherodiogrophic
orotionexhibitso greoteropeningcloselo the
screw,whichis reducedtowordsthesuperiorospectof thenosolcovity.Thisconfirms
thetriongulor shopeo[ the moxilloryopening,withthe censuture
tre of rototioncloseto the fronto-moxillory
(Bocetti
ol,
I
996;
Cross
er ol, 2001; Comeronel
o n d M c D o n o l d , 2 0 0 0 ;d o S i l v o F i l h oo n d
CopelozzoFilho,200 i ; Mozzieroet ol, 1996).
The oim of this poper is io comporeihe rodiogrophictronsverse
chongesproducedby ropid
moxilloryexponsionwith o modifiedHoos exrodiogrophs
ond spiponderusingconveniionol
tomogrophy.
rol computerized
ochievedin 9 doys with o lineoropeningof the
screw of 7.2 mm Eoch completetr-rrno[ the
screwz is equivolentto 0.8 mmo[ opening.The
imoge
exponderwos removedfor post-freotment
evoluotion
RESULTS
Comporisonof ihe occlusolrodiogrophsof the
m o x i l l o( F i g s3. o - d ) o n d c o n v e n t i o n o n
l d to4o-d)
mogfophiconteriorviews
ofthefoce(Figs.
ollowsthe inferpretolion
of chonges.Theimoges
susuggeslo wider openingo[ the intermoxillory
posfero.ontelure on infroorolrodiogrophsond
by the width
rior rodiogrophs,os demonstroted
leoding
the
professionol
of the rodiolucent
oreo,
to overeslimote
ihe reolorthopoediceffectof exponsionos observedby the computedtomogrophicimoges(Figs.5o - d).Thisfoctmoybe exploinedby the superimposition
o[ imogesof the
totd, losste, 'wh,,dr,ir'rreuses ',he rod,oloterty
MATERIALS
AND METHODS
of lhisoreo on the postero-onterior
rodiogrophs.
In on ottemptio checkquontitotively
theoccurocy
Thisstudyilluskotes
the keotmentof one potient, of the evoluotionof the dentol ond skeletololtero boy oged 7 yeorsond 6 monthsThe clinicol olionsby meonso[ posleroonterior
rodiogrophs
exominolionreveoledolresioof the moxillory comporedto thecoronolsectionimogesochieved
in o biloterolposterior in o spirolcomputedtomogrophy,
bosolbone,whichresulled
meosurements
crossbite.
Theincisors
were in edgeJo-edge
relo- were obtoinedof theseexominotions
before(T1)
t i o n s h i p( F i g s l. o - d ) . T h e t r e o t m e nptl o n c o m - ond immediolely
ofterRME(T2l{Figs6o-d)
prisedthe useo[ ropid moxillorylroctionlo exThe meosurements
evoluotedon the postero-onpondthemoxilloto correcithecrossbite
followed leriorrodiogrophs
were os follows:
- inlerprosthion
by moxilloryprolroctionheqdgeqrto correctthe
distonce(lP)
- d i s t o n c eb e t w e e nf h e o n t e r i o rn o s o l s p i n e
Closslll incisorrelotionship
ond improvethe on(ANS)
tero-posterior
skeletolpotlern.
- nosolcovirywidth (NCW)
Dentolond skeletolchongeswere onolyzedby
two differentrodiogrophicimoginglechniques: - inlermolordistonce{lMS),befweenthe moxilrodiogrophs
rodiolory mororS
conveniionol
lpostero-onlerior
g r o p ho n d o c c l u s orlo d i o g r o p h
o f l h e m o x i l l o ) - inteduberosify
distonce{lT}.
ond the spirolcomputedtomogrophy{CT),with
I mm slicesond 40 s exposuretime,for three-di- Accordingto the methodology
describedby do
mensionol
reconstruction
of thecrqniofociol
skuc- S i l v oF i l h oe t o l l 19 9 5 J ,t h em e o s u r e m e n
e tvso l '
iuresusingo SomoiomPlus4r. Therodiogrophs uotedon thetomogrophic
imogewereosfollows:
were tokenon two occosions:
beforetreotment - nosolcovitywidth (NCWI
- inlermolordistonce(lMS),betweenthe moxil(T1l ond immediotely
ofter the octivephoseof
moxilloryexponsion(T2)
rorymorors
- intertuberosity
A m o d i f i e dH o o se x p o n d e(rF i g s . 2 bd, , f ) w o s
distonce(lT).
usedond exponsionwos initioted24 hoursofter
perdoy(2 qr-ror- The two techniques
itsplocementwith
1 completeturn
for ossessing
the intermoxiller lurn incremenfs
in the morning,ond onother lory sutureopeningshowsomesmolldifferences
(Toble1). Thesedifferences
2 in the ofternoon).
Approprioteexponsron
wos
could be produced
by the lorgeomountof superimposition
of fociol
ond croniolstructures
ond theoblectfilmdistonce
I S i e m e n sF,o r c h h e i m
G,e r m o n y
on theposlero-onlefior
rodiogrophs,
whichyields
2 O r d e r n o . 6 0 0 . 3 0 3 ,D e n t o u r u ml s, p r i n g e n ,
(mognificotion)
distortions
ond consequently
imGermony
poirsthe interpretotion
of obtoinedimoges
208
Vol 1, No 3, 2004
Orthodontics
Rizzolfo el ol, Roprd Moxillory Exponsion
Figs.lo-d Initiolintroorolphotogrophsof the boy oged 7 yeors
6 months.
Figs.2o-f Frontolond moxrllory
occlusolphotogrophs
of the potientdemonskoiing
o kiongulor
shopeof thedentolorchdue to
theskeletol
deficiency
whenthe
opplioncewos fitted(o, b), ofter
9 doys172 mm ol opening)
(c,d), ond ofier 1 1 doys {8.8 mm
of opening){e, f).
OrfhodonticsVol 1, No 3, 2OO4
209
Rizzollaef ol, RopidMoxillory Exponsion
F i g s . 3 o - d F ul i n k o o r ool c c l u s o l
rodiogrophs
prior
ond close-ups
ro cemeniotion
of RME(o, b), ond
ofter9 doys (c,d)
Figs.4o-d Rodiogrophic
vrews(c,d) priorto RME(o, c), ond ofter9 doys (b, d)
{PAskul) (o, b), ond tomogrophrc
210
OrfhodonticsVol 1, No 3, 2OO4
Rizzolloel ol, RopidMoxillory Exponsion
Figs.5o-d 3D reconsiruction
ol
fie croniofociol
struclures
by
meonsof spirolcomputed
lomo,
grophy from differentperspectives
demonslroting
the morphology
ond degreeof openingof theintermoxillory
sutureofbr 9 compleleturnsof lhe exponsion
DrscuSstoN
oted by meonsof postero-onterior
rodiogrophs
(PA).When evoluotingRMEin 32 childrenoged
Theliiefoture
stotes
thotlheincreose
oftronsverse 5lo I 1 yeorsby usingPArodiogrophs,
do Silvo
dimensions
in themoxilloryorchofterRMEore for
Filhoet ol (i 995J observedon increoseof op.
the mostport due to on orthopoediceffectproproximotely
4.7 nn, 2.6 mm ond 2 I mm in the
duced during octivotion,yieldingon enhonce. interprosihion
ond inter-onterior
nosolspinedis"
menlin bone mossond in dentolorch perimeter lonces,ond in ihe nosolcovitywidth,respectively.
(Adkinset ol, 1990; Hoos,19ZO;McNomoroet
Theinter.tuberosify
distoncepresentedon increose
o l , 2 0 0 3 ; S p i l l o noen d M c N o m o r o 1, 9 9 5 ) .T h i s of 2.8 mm,whereosthe moxilloryinter-molor
disorthopoediceffectis hequentlyobservedby the
toncehod increosedby obout 5.5 mm,demonorthodontist
throughocclusolrodiogrophs
of lhe
strotingthe remorkoble
contribufion
of dentolol,
moxillo,ond clinicollythroughthe openingof o
tefotionsto lhe correctionof the mqlocclusion.
diostemobetweenthe moxillorycentrolincisors. By meonsof posiero-onlerior
rodiogrophs,
Cross
In young potients,it is ossumedthol the incisors ond McDonold(2000) observedo smollyet sigore seporoted
oboutholfthedistonce
of theopen- nificontincreose(obout1 1 mm)in the moxillory
ing of the screwduringthe octivestogeo[ ex,
skeletol
widthofterlheropywith RME.ThesepoponsionHowever,lhe
omountof suchseporolion rotionof the intermoxillory
sulureot lhe levelof
shouldbe corefr-'lly
monifored
os o porometer
for
the onteriornosolspinewos 3.2 mm.On lhe oth,
indicotionof the omountof suiureopening.
er hond.theinter.molor
distonce
betweenthemoxFromo quonlitolive
stondpoint,
the tronsverse
olillorymolorsdisployedo significont
incfeosedurlerotionsinducedby RMEore commonlyevolu. ingkeotment,
whichwosobout5.5 mm.Thenosol
OrfhodonticsVo/ 1, No 3, 2004
211
Rizzot+o
el ol, Ropid Moxi//ory Exponsion
Figs.6o-d Cepholomekicmeo.
suaemenls
undedokenon lhe pos.
lerior€nlerior
rodiogrophs,
before
{o} ond ofter9 doysol RME(b).
r M s{ . ) ,r T ( . }r,P ( . } , A N S) (
ond NCW (. ). Tronsverse
lineor
meosurements
modeon coronol
tomogromsbefore ond ofter 9
doysof RME(c,d)
covitywidthshowedo meonincreoseof 1 0 mm.
Therefore,
the reol tronsverse
increosein moxill o r yb o n eb o s e{ 1. 1 m m }o c h i e v e b
dymeonsof
the RMEwos quitemild.
TobleI reveols
thottheresults
obtoinedintheprevoluessimilorto
sentpotientreportdemonstrote
thosedescribedin the literoture
for orrmeosure.
mentsevoluoled.
The isoloiedtomogrophyof the moxilloplone
(Figs.5b-dIpresents
o lorgeropeningof the intermoxillory
sutureot lheonteriorpolotqloreo up
to lhe incisive
loromen,witho smolleropeningol
the posterlorpolololoreo.Thus,it is possibleio
defislole thof,whenevero skeletoltronsverse
ciencyis present,wiih need for o significont
increosein lhe bone bose,over-correction
o[ ihe
moxilloryexponsionis fundomeniol
ond should
not be bosed iuston the honsverse
relotionship
befweenthe dentolorches.
Thetomogrophic
of ihe polienlillus
exominotion
trotedthot,despitethecorrection
of the poslerior
crossbife,
onlyo smollmognitude
of olterolionon
the opicolboseswos observed,withossocioiion
of o lorge dentoleffectto RME.lt shouldbe re212
thotthe lorgeincreosein the inter-momembered
lor distoncebetweenthe moxillorymolors(5.5
mmobservedby thePArodiogrophs
ond 6 0 mm
observedby ihe computedtomogrophies)
observedin thisDotientis ossocioted
with o smoller
effecton the moxillorybone bose (3.0 mm observedby the PA rodiogrophsond 2.0 mm observedby the computedlomogroms).
Thisleods
us to believein o greoterdentolrotherthon orthopoediceffect,moinlytokingintooccountlhe
widih of openingo[ the intermoxillory
sulureon
t h et o m o g r o p hi m
c q g e{ F i g . 5 d ) .
Accordingto Hoos{1980), one o[ lhe moinfoctorsrelotedto relopseconcernsihe instobility
of
buccoltippingof the onchorogeteethond orching of theolveolorprocess.
Thus,onlytheexponsion of the moxillorybony bosesochievedby
meonsof suturolexponsionis stoblein the long
term.Therefore,
the qchievement
of o limitedeffecton the bone bose could bringobout limitoiionsin theoutcomeofthistheroov.Thisstotement
wosfurthercorroboroted
by thefindingsof Krebs
(l 964) ond Linder-Aronson
ond [indgren{ I 979),
who stotedthottheinter-molor
disionces
disoloved
Orthodontics
Vol 1, No 3, 2004
Rizzoto et ol, Ropid Moxrllory Exponsion
rodiogtophs
ond coto'
ochievedby meonsof postero-onlerior
beforeond ofterexponsion
Toble I Meosurements
views{in millimehes)nol tomogrophic
IM
IP
ANS
NCW
RME
53 . 5
59.0
0.0
0.0
2 7. 5
RME
59 . 0
62.O
45
30
29.5
5.5
RME
50.0
5 7. 0
RME
56 . 0
59.0
3.0
6.0
2.0
4.5
3.0
20
29.0
31.0
2.0
sutureby computedtoing of the intermoxillory
relopsesof obout45% of the initioldistoncelofhosto be removedsoon
yeors
mogrophy,
the
opplionce
period
5
ofter
ex'
oftero
o[
ler retention)
whenthe moxillory
octivolion
is
completed,
ofter
p ons i o n .
ond
spotiolly
instobleThereore
seporoled
RME
is
determined
mqinbones
thelimitotion
o[
Usuolly,
relopse
oftertemfore,
ihe
risk
of
on
immediote
of the octi.
ly by clinicolcriterio,with inierruption
present,
the
opplionce
is
ever
of the ctoss- pororyremovolof
votionwhen o smollovercorrection
required
[or
the
tomogrophy
biteis ochievedor whenthereis conioctbetween eventhoughthelime
in this
is just40 seconds.
In the potientpresenled
the polotolcuspso[the moxillorymolorsond the
immediotely
ofpopertheexponderwosreploced
molors.Thiswoy,
buccolcuspsof the mondibr-rlor
q
orderto
ovoid
lronsof theimogesin
the omountof ociivotionof the exponsionscfew lerrecording
Additionol
limiiotions
versecollopse
of lhemoxillo.
the width of seporotion
of the
ond consequently
lhe
costof o CTexominotion,
moxillorybonesmighibe regordedos insufficient ore lheconsideroble
ihe positioning
of the poto stondordize
difficulty
orthopoedic
effect.In on otto yieldo significont
ondthediscomfort
oi
iient'sheodduringtomogrophy
lemptio ochieveon increosein theoltefotions
produceduponremovolof theexponder.
the levelof the opicolbose,the octivoiionof the
up lo its moxiexponsionscrewwos mointoined
m u mw i d t hl 1 1 m m j( F i g s2 o - [ ) , s i n c e t h e i m o g e s
ochievedon thecomputedtomogrophyreveoled coNcrustoN
the limitedorthopoediceffectobtoinedwith iust
disTheincreose
in nosolcovitywidth,inter-molor
2.2 mm of octivotion
distoncewos 2.0 mm,
so stronglyodvocoted tonceond inter-luberosity
Thus,the over-correction
on
meosured
3 0 mm ond 5.5 mm,respectively,
by Hoos,seems
to be theonlyoptionin coseswith
Accord- t h e P A r o d i o g r o p hosn d 2 . 0 m m ,2 0 m m o n d
lorge skeleiolkonsversediscreponcies.
rmoges.
6.0 mm colculotedby the tomogrophrc
ing io lhe someouthor,RMEmustcompriseon
with 3D reconstrucSpirolcompuledtomogrophy
openingo[ the screwlo o minimumof ] 2 mm in
ofiheden'
methodforevoluqtion
tionison eFlecfive
orderto yieldo lorgerincreosein moxillorybone
inducedby RME.
olterotions
This tol ond skeletol
the moxillorysutures.
boseond disorticulote
Thisstudyolsofound:
theropeutic
opproochmoy explointhe loct thot
onotomicdeioilsprovided
1 Thecomprehensive
Hoospresents
the bestouicomesfoundin the litby thisCT exominolioncomporedto the conerotureos regordsthe longlermslobilityof RME
limventionolrodiogrophssuggestremorkoble
l A z i z ie t o l , 19 9 9 ; H o o s1 9 8 l ; R i b e i r oI 9 9 9 ) .
itotionsof thereoldegreeof openingof theinSpirolcomputedtomogrophywos demonstroted
olienoverestimoted
by coniermoxillory
suture,
of the
to be qn excellentmethodfor delineotion
exominotions;
ventionolrodiogrophic
ond rotiosbetweendentolond skelemognitudes
o[ the exponsionmusl
toleffects
inducedby RME.However,thismethod 2. A lorgeover-correction
tronsverse
inbe ochievedwhen o significont
is olmosiunvioblein doily proctice,sinceit recreosein moxillorybone boseis desired.This
quiresremovolof the opplioncefor ochievemenl
shouldnotbe bosedonlyon ocover-correction
o f t o m o g r o p h iicm o g e sd, u e t o d i s t o r t i o nosb porometers,
presence
but moinlyon thedegreeol
in
the
o[
clusol
servedon this exominolion
de[iciency
of the moxillo.
the
reol
tronsverse
For
visuolizoiion
of
openmetollicstructures.
OrlAodonlicsVol 1, No 3, 2OO4
213
Rezoftoel ol, RopidMoxillory Exponsion
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