The management of transverse maxillary deficiency

Global Developmental Delay in Children with Full Mouth Rehabilitation: A Case Series

Global developmental delay (GDD) is a chronic neurological disturbance that includes defects in one or more developmental domains. Although some diagnosed delays are benign, certain presentations are more worrisome. The developmental domains can be motor, cognitive, daily activities, speech or language, and social or personal development. The etiology of GDD can be prenatal, perinatal, or postnatal. It can be diagnosed early in childhood as the delay or absence of one or more developmental milestones. Hence the role of pediatric dentists and pediatricians becomes more crucial in identifying this condition.

How to cite this article

Thimmegowda U, Chikkanarasaiah N, P A, et al. Global Developmental Delay in Children with Full Mouth Rehabilitation: A Case Series. Int J Clin Pediatr Dent 2023;16(3):522-527.

Midpalatal Suture Maturation Stage in 10- to 25-Year-Olds Using Cone-Beam Computed Tomography-A Cross-Sectional Study

In this study, we aimed to evaluate the frequency of midpalatal maturational stages in a Chilean urban sample of adolescents, post-adolescents and young adults, associated with chronological age and sex, by assessing CBCT scan images. Tomographic images in axial sections of the midpalatal sutures from 116 adolescents and young adults (61 females and 55 males, 10-25 years old) were classified according to their morphologic characteristics in five maturational stages (A, B, C, D and E), as proposed by Angelieri et al. The sample was divided into three groups: adolescents, post-adolescents and young adults. Three previously calibrated examiners (radiologist, orthodontist and general dentist) analyzed and classified the images. Stages A, B and C were considered to be an open midpalatal suture, and D and E were considered to be a partially or totally closed midpalatal suture. The most frequent stage of maturation was D (37.9%), followed by C (24%) and E (19.6%). The possibility of finding closed midpalatal sutures in individuals of 10 to 15 years was 58.4%, and in subjects aged 16 to 20 and 21 to 25 years, it was 51.7% and 61.7%, respectively. In males, Stages D and E were present in 45.4%; for females, this prevalence was 68.8%. Individual assessment of the midpalatal suture in each patient is of crucial importance before making the clinical decision of which is the best maxillary expansion method. Due to the extensive calibration and training required, it is advisable to always request a report from a radiologist. Individual evaluation with 3D imaging is recommended because of the great variability observed in the ossification of midpalatal sutures in adolescents, post-adolescents and young adults.

Maxillary Expansion and Its Effects on Circummaxillary Structures: A Review

Transverse maxillary discrepancies are the most common. The narrowed upper arch is the most prevalent problem an orthodontist encounter while treating adolescent and adult patients. Maxillary expansion is a technique used to increase the upper arch's transverse dimension to apply forces to widen the upper arch. For young children, a narrow maxillary arch has to be corrected using orthopedic and orthodontic treatments. In an orthodontic treatment plan, it is crucial to update transverse maxillary defeat. There are various clinical manifestations associated with a transverse maxillary deficiency which include a narrow palate, crossbite mainly seen in posteriors (unilateral or bilateral), severe crowding in anterior teeth, and cone-shaped hypertrophy can be seen. Some frequently used therapies for constricted upper arch include slow maxillary expansion, rapid maxillary expansion, and surgically assisted rapid maxillary expansion. Slow maxillary expansion requires light and constant force, whereas rapid maxillary expansion needs heavy pressure for activation. The surgical-assisted rapid maxillary expansion has gradually become popular to correct transverse maxillary hypoplasia. The maxillary expansion has various consequences on the nasomaxillary complex. There are multiple effects of maxillary expansion on the nasomaxillary complex. Mainly, the effect is seen on the mid-palatine suture along with the palate, maxilla, mandible, temporomandibular joint, soft tissue, and anterior and posterior upper teeth. It also affects functions like speech and hearing. Information on maxillary expansion is provided in depth in the following review article, along with its various effects on the surrounding structure.

Expansion in the absence of crossbite – rationale and protocol

Transverse maxillomandibular discrepancies are a major component of several malocclusions. Clinically, posterior crossbite is a common and valid indicator of maxillary transverse problems and orthopedic and orthodontic forces are routinely used to correct maxillary transverse deficiency. However, crossbite and transverse discrepancies are not a homologous group but must be viewed as a continuum with varying degree of abnormality. The etiology, diagnostic protocol, rationale, and procedures employed for correcting maxillary transverse discrepancy in the absence of crossbite are discussed in the article.

Controlled Molar Inclination during Maxillary Dental Expansion Using a Straight Rectangular Archwire

Purpose

The purpose of this study was to examine whether the amount of transversal dental expansion, controlled using a straight rectangular beta-titanium alloy (TMA®) wire, has an influence on changes in maxillary first molar inclination.

Materials and Methods

Twenty patients requiring bilateral maxillary dental arch expansion were treated using a 0.018”-slot preadjusted edge-wise fixed appliance. Once leveled and aligned, the maxillary dental arches were expanded using a 0.016” × 0.022” straight TMA® wire. Changes in arch width and maxillary first molar inclination were assessed before (T0) and after (T1) expansion using three-dimensional scanned models. Mann–Whitney U-test, Wilcoxon signed-rank test, and Kruskal–Wallis test were used, where appropriate, to compare changes between and within groups.

Results

Intermolar width expanded at a rate of 0.8 ± 0.3 mm/month, and first molar buccal crown tipping occurred at 2.1° ± 1.2° (P < 0.05). Changes in inclination between minor expansion (1.0–2.5 mm) and moderate expansion (2.6–4.0 mm) groups were not statistically significant (1.8 ± 0.5 vs. 2.2 ± 1.2; P > 0.05).

Conclusions

Use of a straight rectangular TMA® wire in conjunction with a fixed orthodontic appliance successfully expanded the maxillary dental arch. The amount of expansion had no effect on molar inclination.

RANK/RANKL/OPG Expression in Rapid Maxillary Expansion

The aim of this study was to evaluate osteoclastogenesis signaling in midpalatal suture after rapid maxillary expansion (RME) in rats. Thirty male Wistar rats were randomly assigned to two groups with 15 animals each: control (C) and RME group. RME was performed by inserting a 1.5-mm-thick circular metal ring between the maxillary incisors. The animals were euthanized at 3, 7 and 10 days after RME. qRT-PCR was used to evaluate expression of Tnfsf11 (RANKL), Tnfrsf11a (RANK) and Tnfrsf11b (OPG). Data were submitted to statistical analysis using two-way ANOVA followed by Tukey test (a=0.05). There was an upregulation of RANK and RANKL genes at 7 and 10 days and an upregulation of the OPG gene at 3 and 7 days of healing. Interestingly, an increased in expression of all genes was observed over time in both RME and C groups. The RANKL/OPG ratio showed an increased signaling favoring bone resorption on RME compared to C at 3 and 7 days. Signaling against bone resorption was observed, as well as an upregulation of OPG gene expression in RME group, compared to C group at 10 days. The results of this study concluded that the RANK, RANK-L and OPG system participates in bone remodeling after RME.

Maxillary and mandibular dentoalveolar expansion with an auxiliary beta-titanium arch

Traditionally, adult patients with mild to moderate transverse discrepancies are treated with a combination of slow maxillary expansion with palatal appliances and expanded archwires. In this case report, we describe an alternative approach for anterior crowding and excessive buccal corridors in a 20-year-old man who was treated using a beta-titanium auxiliary expansion archwire. The perceived benefit of this approach was related not only to the esthetic improvement of the smile resulting from elimination of the anterior crowding and reduction of the buccal corridors, but also to the minimal disruption of the patient's speech, which was his main functional concern.

Relationship between maturation indices and morphology of the midpalatal suture obtained using cone-beam computed tomography images

Objective

The purpose of this study was to determine whether predicting maturation of the midpalatal suture is possible by classifying its morphology on cone-beam computed tomography (CBCT) images and to investigate relationships with other developmental age indices.

Methods

The morphology of the midpalatal suture was assessed by using CBCT images of 99 patients. Axial plane images of the midpalatal suture were classified into five stages according to the classification scheme. To make the assessment more accurate, the morphology and fusion of the midpalatal suture were additionally investigated on coronal cross-sectional planar images and volume-rendered images. Bone age was evaluated using the hand and wrist method (HWM) and cervical vertebrae method (CVM); dental age (Hellman's index), sex, and chronological age were also assessed. To evaluate relationships among variables, Spearman's rho rank test was performed along with crosstabs using contingency coefficients.

Results

The HWM and CVM showed strong correlations with the maturation stage of the midpalatal suture, while other indices showed relatively weak correlations (p < 0.01). Through crosstabs, the HWM and CVM showed high association values with CBCT stage; the HWM demonstrated slightly higher values (p < 0.0001). Based on the HWM, the midpalatal suture was not fused until stage 6 in both sexes.

Conclusions

Among developmental age indices, the HWM and CVM showed strong correlations and high associations, suggesting that they can be useful in assessing maturation of the midpalatal suture.

Longitudinal quantitative evaluation of the mid-palatal suture after rapid expansion using in vivo micro-CT

New bone formation is known to occur between the opened palatal bones after rapid mid-palatal expansion (RME), although the time-dependent changes in the mid-palatal suture after RME have not been fully examined. Thus, we investigated time-dependent morphological changes in the mid-palatal suture using in vivo micro-computed tomography (mCT) and the expression of bone morphogenetic factors. RME was performed by inserting a 1.5-mm-thick circular metal ring between the maxillary incisors of rats, and morphological changes in the mid-palatal suture were investigated using in vivo mCT imaging after RME. Bone morphogenetic protein 2 (BMP-2) and insulin-like growth factor-I (IGF-I) expression in the suture were also examined using reverse-transcription polymerase chain reaction and immunohistochemistry. The bone volume of the mid-palatal suture decreased after RME to a minimum of -0.34mm(3) on day 12, then increased with bone formation over time and reached -0.13mm(3) on day 24. Significant increases in BMP-2 and IGF-I mRNA expression after RME were found on day 3 compared with day 0. By immunohistochemistry, BMP-2 and IGF-I were detected in osteoblasts on days 5 and 7, in endothelial cells of blood vessels, and fibroblasts on day 7. Expansion of the mid-palatal suture continues for 12 days after a single RME, and restoration requires more than 30 days. Additionally, BMP-2 and IGF-I may play important roles in the restoration process.

Maxillary Expansion

Maxillary transverse discrepancy usually requires expansion of the palate by a combination of orthopedic and orthodontic tooth movements. Three expansion treatment modalities are used today: rapid maxillary expansion, slow maxillary expansion and surgically assisted maxillary expansion.This article aims to review the maxillary expansion by all the three modalities and a brief on commonly used appliances.