Circumaxillary Suture Strain during Midpalatal Suture Opening and Maxillary

Protraction

THESIS

Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in
the Graduate School of The Ohio State University

By
Remigius Jackson, B.S., D.D.S.
Graduate Program in Dentistry

The Ohio State University

2012

Master's Examination Committee:

Dr. Zongyang Sun, Advisor
Dr. Henry W. Fields, Jr.
Dr. William M. Johnston
 Copyright by

Remigius Jackson

2012
 ABSTRACT

Objective: Midpalatal suture expansion has been proposed as useful to assist maxillary

protraction in preadolescent patients with maxillary deficiency despite a lack of direct

mechanical data. This study measured mechanical strain (deformation) in several

circumaxillary sutures caused by maxillary protraction before and after midpalatal suture

opening (MSO). Methods: Six fresh skulls of 1-month old piglets (equivalent to human

preadolescent age) were used. Strain gages were implanted at the surface of 5

circumaxillary (MZ: maxillary-zygomatic; MP: maxillary-premaxillary; ML: maxillary-

lacrimal; TZ: temporal-zygomatic; IN, internasal) sutures. Through arms anchored on

maxillary molars, maxillary protraction was performed by using varied force levels (100,

250 and 500g) generated by latex elastics. Midpalatal suture opening was achieved by

inserting metal shims with standardized thickness (1-5mm) into this suture.

Circumaxillary suture strains were recorded during maxillary protraction and MSO.

Strain changes with protraction force level and MSO amount were compared by repeated

measures ANOVA. Results: When isolated effect was considered, maxillary protraction

produced compressive and tensile strains at the MP and MZ sutures, respectively. MZ

suture tension increased (in absolute magnitude) significantly (p=0.035) with protraction

force level but decreased significantly with the amount of MSO (p=0.026). . MSO alone

caused tensile and compressive strains at the MP and MZ sutures, respectively, both of

which increased significantly (in absolute magnitude) with the amount of MSO (p<0.05).

ii
When strain changes relative to initial baselines (before any protraction or MSO) were

calculated, the MP and MZ sutures were dominated by MSO-generated strains (tensile

and compressive, respectively). Generally, strains in the other three sutures tested were

smaller than the MP and MZ sutures. Conclusion: The strains at the anterior and

posterior circumaxillary sutures produced by the opening of the midpalatal suture were

larger in magnitude and opposite in dynamics compared to those generated by maxillary

protraction. Therefore, the immediate mechanical effect caused by midpalatal suture

opening does not enhance maxillary protraction mechanics.

iii
Dedicated to my family: My mother, Jean; my father, Leo; my sisters, Keyne and

Lishawa, and my brother Davalos

iv
 Acknowledgments

First, I would like to express my love for my Lord and Savior, Jesus Christ. He

continues to lead and guide me. “I can do all things through Christ who strengthens me.”

Next, I am grateful and blessed to have a loving family. They have encouraged

me throughout my life.

I would like to thank my thesis advisor, Dr. Zongyang Sun, for his support and

guidance throughout my residency. I appreciate all of his time and effort towards this

project.

I would also like to thank other members of my committee: Dr. Henry Fields and

Dr. William Johnston.

I would like to thank the Delta Dental Master’s Thesis Award Program for its

funding of this research project.

v
 Vita

May 30, 1982 .................................................Born- Orange, Texas USA

2004................................................................B.S. Biology
McNeese State University
Lake Charles, LA

2009................................................................D.D.S.
Meharry Medical College
Nashville, TN

2009 to present ..............................................Graduate Resident in Orthodontics

The Ohio State University
Columbus, OH

Fields of Study

Major Field: Dentistry

Specialty: Orthodontics

vi
 Table of Contents

Abstract ............................................................................................................................... ii

Dedication. ......................................................................................................................... iv

Acknowledgments............................................................................................................... v

Vita..................................................................................................................................... vi

Table of Contents .............................................................................................................. vii

List of Tables ................................................................................................................... viii

List of Figures .................................................................................................................... ix

Chapter 1: Introduction ....................................................................................................... 1

Chapter 2: Materials and Methods .................................................................................... 11

Chapter 3: Manuscript....................................................................................................... 17

Chapter 4: Conclusions ..................................................................................................... 53

Bibliography ..................................................................................................................... 54

vii
 List of Tables

Table 1. MZ-Relative strain measurements ...................................................................... 35

Table 2. MP-Relative strain measurements ...................................................................... 36

Table 3. TZ-Relative strain measurements ....................................................................... 37

Table 4. IN-Relative strain measurements ........................................................................ 38

Table 5. LM-Relative strain measurements ...................................................................... 39

Table 6. MZ- Cumulative strain measurements ................................................................ 40

Table 7. MP- Cumulative strain measurements ................................................................ 41

Table 8. TZ- Cumulative strain measurements ................................................................. 42

Table 9. LM- Cumulative strain measurements ................................................................ 43

Table 10. IN- Cumulative strain measurements ............................................................... 44

viii
 List of Figures

Figure 1.Experimental Procedure ..................................................................................... 45

Figure 2. Apparatus used to stabilize pig cadaver heads………………………………...46

Figure 3. Suture sites for strain measurements ................................................................. 47

Figure 4. Strain recording analysis. .................................................................................. 48

Figure 5. Relative strain caused by protraction. ............................................................... 49

Figure 6. Cumulative strain caused by expansion strain .................................................. 50

Figure 7. Cumulative strain caused by protraction from the start of the experiment. ...... 51

Figure 8. Protraction facemask for humans……………………………………………...52

ix
 Chapter 1: Introduction

Treatment of Class III malocclusions remains to be a challenge for many

practitioners. Class III skeletal growth can result from a retrusive maxilla, a protrusive

mandible, or a combination of both. Although many once believed Class III problems

only involve the mandible, more recent studies show that the majority of Class III cases

involved maxillary retrusion (Ellis and McNamara, 1984; Guyer et al., 1986).

There are different techniques for treatment depending on which jaw is at fault.

Prognathic mandibles are usually treated with surgery, whose timing is important because

of the risk of outgrowing the surgical correction. A series of cepholagrams is needed to

confirm the lack of continued growth of the mandible. At that point, surgery can be

successfully carried out. Prognathic mandibles can be camouflaged if the patient has a

favorable profile. In these cases, positive overjet can be accomplished with interproximal

reduction, extraction of a lower incisor or extraction of two lower premolars. Chin cup

therapy has been attempted for growing patients, but it appears to have only transient

effects.

Children with deficient maxilla also have several treatment options: surgery

following growth completion, camouflage, or growth modification. Surgery is often

recommended for nonsyndromic patients with severe maxillary deficiencies. Syndromes

such as cleft lip and palate and cleidocranial dysplasia are also often treated with surgery

1
to move the maxilla forward. As with camouflage for prognathic mandibles, patients with

favorable profiles, positive overjet can also be achieved with extractions of two lower

premolars or even a simple extraction for a lower incisor. The third option is growth

modification, an option available for patients with mild class III skeletal relationship.

With this type of treatment, age is very important. Unlike growth modification for class II

which is best to begin around the growth spurt, class III growth modification is best to

begin before the age of ten (Kim et al., 1999). Growth modification is accomplished by

protracting the maxilla using a reverse pull headgear or face mask. Using the forehead

and the chin as anchorage, force can be directed to the maxilla. It is commonly thought

that the mechanism of maxillary growth modification is through mechanical separation of

the maxilla from the cranial base. This separation occurs at the circumaxillary sutures

where appositional changes occur within the sutures to maintain its relationship (Nanda,

1978).

Class III growth modification has been successful in a number of cases. Studies

showed about a 3mm change in the anterior-posterior (A-P) position of the maxilla (Chen

et al., 2011; Gautam et al., 2009; Jager et al., 2001; Kapoor and Kharbanda, 2011; Lee et

al., 2010; Ngan et al., 1996a; Vaughn et al., 2005). Often in a patient with a Class III

skeletal discrepancy, a posterior crossbites are evident. Therefore, some patients will

need expansion in the upper arch. With the use of expanders, a number of practitioners

have discovered a downward and forward movement of the maxilla. This is due to the

expansion of the mid palatal suture caused this movement of the maxilla by

2
disarticulating the circumaxillary sutures (Chaconas and Caputo, 1982; Gardner and

Kronman, 1971a; Haas, 1973; Wertz and Dreskin, 1977). With protraction head gear, a

downward and forward movement is also evident. Therefore, some have claimed that

combining the two appliances may cause an increased amount of downward and forward

movement of the maxilla (Vaughn, Mason et al. 2005, Lee, Kim et al. 2010, Gautam,

Valiathan et al. 2009).

Currently, some clinical evidence has been reported to support or refute this

claim. Most of the supporting evidence is based on retrospective studies and a few

prospective studies on humans (Vaughn, Mason et al. 2005), but supporting evidence

from a mechanical standpoint is still lacking. To better understand what occurs in the

circumaxillary sutures during protraction and expansion, it is necessary to understand the

mechanical influence caused by these procedures. The gold standard for evaluating

mechanical responses of bone and sutures to various forces is through strain gauge

measurements (Herring et al., 1996; Herring et al., 2001). In this study, strain will be

measured by attaching strain gages to the surface of the sutures, which will reflect the

immediate deformation between the two bone fronts of the suture during force

application. By doing so, we hope to gain some insight into the mechanical effects of

protraction with or without rapid palatal expansion.

3
 Comprehensive Literature Review and Statement of the Problem

Growth deficiency in the upper jaw (maxilla) is a common and challenging

problem in orthodontics(Kim et al., 1999). Often present with a concave facial profile and

an underbite of anterior teeth, this form of discrepancy causes substantially negative

impact on patient's facial esthetics and function (Ngan et al., 1996b). With no treatment

during patient's growth, jaw surgery is usually required to correct a maxillary deficiency,

which significantly increases patient's cost and chance of complications. It is very

advantageous, therefore, to stimulate the growth of the maxilla during or even before the

growth spurt for such patients.

Effectiveness of Protraction

Maxillary protraction causes the following changes: the maxilla and maxillary

dentition move downward and forward, while the mandible and mandibular dentition

move downward and backward with an uprighting of the lower incisors (Tanne et al.,

1989).The orthopedic effect of protraction headgear is often seen in lateral

cephalometrics. Changes in Sella-Nasion-A point (SNA), Sella-Nasion-B point (SNB),

and A point-Nasion-B point (ANB), are often investigated to compare treatment effects.

SNA increases and SNB decrease after protraction headgear which ultimately increases

the ANB. As the maxilla moves downward and forward, changes occur in the palatal

4
plane with the posterior moving downward. Mandibluar plane angle is increased as the

mandible rotates down and back (Ngan et al., 1996a; Tanne et al., 1989).

Other landmarks can be used to determine the growth of the maxilla. According to

Sung et al (Sung and Baik, 1998) when evaluating anterior nasal spine (ANS) to posterior

nasal spine (PNS), the mean changes of maxillary length in protraction group ranged

from 1.2 mm to 1.5 mm compared with 0.5 mm to 0.9 mm in the untreated group. Ngan

and coworkers (Ngan et al., 1996a) showed 2.0 mm forward movement of point A after 6

months of protraction. Ishii et al.,(Ishii et al., 1987) showed a 2.4 mm forward movement

of the maxilla. Based on these findings, in general, one could expect the maxilla to move

forward about 1 to 3 mm during maxillary protraction.

Expansion

Anatomically, the maxilla is connected with adjacent bones through soft tissue

joints called circumaxillary sutures. These sutures surround the jaw and connect the

maxilla to the skull. Potentially, any opening of the mid-palatal suture may cause an

effect to the surrounding sutures. For a long time, it has been claimed by some clinicians

that a simultaneous expansion of the maxilla can further loosen up these sutures, thus

enhancing maxillary protraction (Timms, 1980; Wertz and Dreskin, 1977).

In 1962, Sicher stated that the circumaxillary sutures are oriented in such a

manner that growth would produce a downward and forward vector of maxillary

movement (Sicher, 1962). Haas agreed by concluding that the opening the mid palatal

5
suture cause the sutures surrounding the maxilla to be disengaged, leading to a downward

and forward movement of the maxilla (Haas, 1973). Later, another study using a three-

dimensional anatomic model also confirmed the downward and forward movement of the

maxilla due to rapid palatal expansion (Chaconas and Caputo, 1982).

Some studies confirmed these effects indirectly by looking at the bony resistances

around the maxilla. These bony resistances consist of any structure that prevents the

maxilla from moving all directions. In 1964, Isaacson and associates recorded the level of

force during opening of the mid palatal suture. He discovered that the major resistance to

the expansion was surrounding areas that articulated with the maxilla (Isaacson and

Ingram, 1964). These findings were confirmed by a similar study shortly after (Zimring

and Isaacson, 1965). Animal studies were also conducted to substantiate these claims.

Starnbach evaluated the effects of maxillary expansion in rhesus monkeys. He concluded

that as a result of mid palatal expansion, concomitant changes occur in surrounding

structures (Starnbach et al., 1966). Furthermore, it was reported that distortions were

present, not only in the surrounding structures, but even in the sutures of the skulls after

using a jackscrew appliance (Gardner and Kronman, 1971b).

Supporting evidence has also been produced by clinical studies on human

patients. Recently (2011), using lateral cephlograms and CT records in eight growing

patients, Leonardi concluded that sutures show bony displacement in response to rapid

maxillary expansion. Although each suture tested was highly variable, he discovered that

6
sutures articulating directly to the maxilla were more affected by the rapid maxillary

expansion therapy (Leonardi et al., 2011).

Protraction with expansion vs. protraction without expansion

Protraction with or without expansion has caused substantial debates over the

years. There have been many studies that focused on the effects of only protraction or

only expansion. There are fewer studies that evaluated the two variables together in the

same study; and even fewer studies that provided a control group.

In a finite element study, stress patterns of various sutures surrounding the

maxilla were measured during protraction with expansion and protraction without

expansion (Gautam et al., 2009). They concluded that the high stresses generated in

various craniofacial sutures after maxillary protraction with expansion are responsible for

disrupting the circumaxillary sutural system and presumably facilitating the orthopedic

effect of the facemask. Another finite element study, conducted by Yu found that with

opening of the mid palatal suture, greater amounts of displacement in the frontal, vertical,

and lateral directions are observed, compared with no opening of the midpalatal suture

(Yu et al., 2007).

7
 These experimental findings, however, were not echoed by clinical studies.

Tortop et al conducted a retrospective study looking at pre-treatment and post-treatment

lateral cephalograms of twenty-eight subjects with Class III skeletal and dental

malocclusions. They divided the subjects into three groups: expansion, no expansion, and

control. They concluded that both treatment procedures were similarly effective in

treating Class III malocclusions (Tortop et al., 2007). Vaughn et al. conducted the first

randomized prospective clinical trial. His study quantified the effects of maxillary

protraction with or without palatal expansion. Forty six subjects were randomly separated

into three groups, one of which was an observation or control group. He concluded that

facemask therapy with or without palatal expansion produced equivalent changes in the

dentofacial complex that led to the improvement of the Class III malocclusion (Vaughn et

al., 2005).

Finally, Kim conducted a meta-analysis that evaluated the effectiveness of

maxillary protraction. He was able to evaluate any differences between protraction with

or without expansion. He found no difference between the groups with and without

palatal expansion except for incisor angulations, which showed greater proclination in the

nonexpansion group (Kim et al., 1999). According to the hierarchy of evidence, a metal

analysis and a randomized clinical trial are the highest quality of evidence. These types of

studies minimized biases. Since both types of clinical studies at the top of the hierarchy

refuted the claim that maxillary protraction is enhanced by rapid palatal expansion, one

8
can see that there was a distinct discrepancy between experimental findings from animals

or mathematical models and clinical data based on human patients.

One critical component missing from the aforementioned animal and

mathematical model studies is direct mechanical data. As a mechanically induced

procedure, strains (deformations) at the circumaxillary sutures during maxillary

protraction with or without expansion may provide us a more fundamental and direct

perspective regarding the dynamics involved in these procedures. The current study was

undertaken to address this aspect.

9
 Specific Aims

The specific aims of this study were to quantify mechanical strains at

circumaxillary sutures and to characterize the dynamics entailed by these strains during

maxillary protraction before and after acute midplatal suture expansion in pig cadavers

Null Hypothesis

Ho1: maxillary protraction before and after maxillary expansion will cause the same

amount of strain increase at circumaxillary sutures. Ho2: The dynamics (tension or

compression) of the circumaxillary suture strains caused by maxillary expansion and

protraction will be the same.

10
 Chapter 2: Materials and Methods

Animal Specimens

Six fresh heads of 1 month old pigs were used in this study with the soft tissues

intact. At this age, pigs are generally comparable to preadolescent humans in terms of

craniofacial maturity (Herring, 1976) and their midpalatal sutures are patent and

responsive to expansion. The pigs were obtained from a local vendor through the

Ohio State University Laboratory Animal Resources. After sedation (Telazol, 6mg/Kg

IM) and euthanasia (pentobarbital, 90mg/Kg IV) the pig heads were removed. To

maintain colleganeous material, all animal heads used in this study were stored at –20°C

and thawed overnight at room temperature before the experiments.

Power analysis

We assumed that suture strain magnitude caused by protraction will increase at

least 2 fold after 5mm of palatal expansion. Therefore, a sample size of six was

determined based on repeated measures ANOVA, with a 3-fold difference in the means

and a 50% coefficient of variance. Using G*Power 3.0 calculation, a power above 90% at

a 0.05 significance level could be reached.

11
Experimental procedure

Pig heads were thawed overnight and protraction appliance was cemented the

next morning (detailed below). Strain gages were placed in identified sutures on the pig

head (detailed below). After the strain gages were secured in place, we began recording

(detailed below) according to the following procedure: baseline Protraction phase,

expansion 1, protraction phase1, expansion 2, protraction phase 2… This procedure

continued until protraction phase 5 was reached (Figure 1).

Protraction appliances

Our protraction appliance was somewhat different than clinical practice.

Clinically, a face mask is delivered to the patient with bilateral 3/8-inch, 8-ounce elastics.

This force magnitude is typically used for the first few weeks of treatment for patient

comfort. After that, the force is increased with the use of 1/2-inch, 14-ounce elastics or

even 5/16-inch, 14-ounce elastics. The direction of elastic traction is forward and

downward. In our experiment, orthodontic bands were fit, adjusted, and cemented on

maxillary third deciduous molars (Dm3). Clinically, maxillary first molars of human

patients are often used, but in 1 month old pigs, the maxillary first molars are not

available for banding yet. As an acceptable alternative, the Dm3 is fully erupted,

functional and stable for banding. The mesial and distal surfaces of Dm3 were reduced

for band space. Once the bands were correctly fitted, extension arms, for protraction,

12
were soldered onto the buccal surface of the bands. These arms were extended to the

mesial of the deciduous canines. Bandlock (3M Unitek) adhesive material was used to

cement the appliance to Dm3. The animal head was secured in a metal frame, which

prevented free movement of the whole head but exerted no additional strain to the head

(Figure 2). Manual stabilization of the cranial portion of the skull was provided to further

prevent whole head movement while permitting displacement of the maxilla.

Protraction was achieved using 5/16”, 6oz orthodontic elastics (Dentsply

International, Inc). These elastics were attached to the extension arms and stretched to the

desired force. The force was measured for each period of protraction using a Dontrix

gage (Dentsply International, Inc). Three force levels (100g, 200g, and 500g) of

protraction were conducted with each force level repeated 3 times (8 seconds/time with 5

second rest intervals).

Expansion Procedure

Tooth borne expanders (Hyrax) or bone-borne expanders (using TADs) were not

used in this study. Based on our pilot experiments, the midpalatal suture in our animals

was difficult to open using those methods because the palate was too thin (0.5-1.5mm in

thickness). Therefore, we manually opened the mid palatal suture using metal shims.

Each shim was 8mmx35mm with 1mm of thickness (customized by Quest technologies,

Inc.). The midpalatal suture was initially accessed by using a scalpel blade. This allowed

for easier placement of the metal shims. This transmitted the forces directly to the

13
skeletal structures and did not complicate the interpretation with forces to the dental

units.

Strain gage placement

Once selected sutures were located, strain gages were placed at their external

surfaces. To assure consistent placement among the subjects, one examiner placed all

strain gages. The placement of gages followed the procedures detailed in a previous study

(Sun et al., 2004). Soft tissue (ie: hair, skin, muscles, fascia, etc.) covering the sutures

were reflected by using a scalpel. The external surfaces of the sutures were treated with

conditioner and neutralizer (Vishay Measurements Group, Raleigh, NC). After treating

the sutures, air was used to dry them. A 2-mm-wide ultra-thin plastic strip was placed

above the sutures to shield them from being glued. Gauges were then attached using M –

Bond 200 adhesive (Vishay Measurements Group, Raleigh, NC). Single element gauges

(C2A-06-125LW-350) were placed perpendicularly to the sutures. The following sutures

were evaluated in this study (Figure 3): maxillary-zygomatic(MZ), maxillary-

premaxillary(MP), maxillary-lacrimal(ML), zygomatic-temporal (TZ ), and internasal

(IN)sutures. No gauge was attached to the midpalatal suture because displacement at this

suture was too large for strain gages to measure.

14
Strain gage recording

Strain gage wires were connected to an amplifier (A2, Vishay) and to the MP150

system (Biopac Systems, Coleta. Calif). AcqKnowledge III software (Biopac) was used

to analyze data from the strain gages. Strain was reported as microstrain (με). Recordings

began with an initial reading to confirm that the system was working properly. A baseline

recording of protraction was next. This included three force levels (100g, 250g, 500g).

The next group of recordings followed experimental procedures described above.

Strain analysis

The strain magnitudes, before and after each activation of expansion and

protraction, were quantified. Strain was measured as deformation of the strain gage,

which recorded the relative deformation between the two bone fronts of the suture rather

than tissue deformation inside the suture. Strain polarity on the sutures was read directly

from the strain gage recordings with an upward waveform indicating tension, and a

downward waveform indicating compression. Strain (ε) is a dimensionless unit that

equals the change in length of an object divided by the original length of the object. The

unit of strain used in this study was microstrain (µε), which equals 1 × 10−6 in/in or

mm/mm (Hylander and Johnson, 1997). The tensile value was represented by a positive

value and the compressive strain was represented by a negative value. An example is

shown in Figure 4. In this example, the average strain was measured from the black line.

The red line indicates the rest period where protraction was halted.

15
Statistical analysis

Mean values were compared using repeated measures ANOVAs. This statistical

method was chosen because multiple repeated measurements were taken from the same

sutures under a series of procedures in each animal. This method minimized the influence

of individual differences in animals on the variations caused by independent variables

being tested. In this study, strain was identified as the dependent variable while, both

protraction and expansion was recognized as the independent variables. A p value ≤.05 is

considered statistically significant, and a p value ≤ .001 is considered highly significant.

A p value ≥.05 and ≤.15 is considered a tendency towards significance but needs further

studies to verify the results.

16
 Chapter 3:

Manuscript: Circumaxillary Suture Strain during Midpalatal Suture Opening and

Maxillary Protraction

Abstract

Objectives: Midpalatal suture expansion has been proposed as useful to assist maxillary

protraction in preadolescent patients with maxillary deficiency despite a lack of direct

mechanical data. This study measured mechanical strain (deformation) in several

circumaxillary sutures caused by maxillary protraction before and after midpalatal suture

opening (MSO). Methods: Six fresh heads with intact soft tissue of 1-month old piglets

(equivalent to human preadolescent age) were used. Strain gages were implanted at the

surface of 5 circumaxillary (MZ: maxillary-zygomatic; MP: maxillary-premaxillary; ML:

maxillary-lacrimal; TZ: temporal-zygomatic; IN, internasal) sutures. Through arms

anchored on maxillary molars, maxillary protraction was performed by using varied force

levels (100, 250 and 500g) generated by latex elastics. Midpalatal suture opening was

achieved by inserting metal shims with standardized thickness (1-5mm) into this suture.

Circumaxillary suture strains were recorded during maxillary protraction and MSO.

Strain changes with varied protraction force levels and MSO amounts were compared by

repeated measures ANOVA. Results: When isolated effects was considered, maxillary

protraction produced compressive and tensile strains at the MP and MZ sutures,

respectively, both of which increased significantly (p<0.05) with protraction force level

17
but decreased significantly (p<0.05) with the amount of pre-protraction MSO (p<0.05).

MSO alone caused tensile and compressive strains at the MP and MZ sutures,

respectively, both of which increased significantly with the amount of MSO (p<0.05).

When strain changes relative to initial baselines (pre-MSO and pre-protraction) were

considered, strains at the MP and MZ sutures were dominated by MSO-generated strains

(tensile and compressive, respectively) with lessening effects from maxillary protraction.

Generally, strains in the other three sutures tested were smaller than the MP and MZ

sutures. Conclusion: The strains at the anterior and posterior circumaxillary sutures

produced by the opening of the midpalatal suture were larger in magnitude and opposite

in dynamics compared to those generated by maxillary protraction. Therefore, the

immediate mechanical effect caused by midpalatal suture opening does not enhance

maxillary protraction mechanics.

18
 Introduction

Growth deficiencies in the maxilla are problematic for achieving ideal

occlusion, facial skeletal relations and facial esthetics in orthodontics. With

limited treatment options and minimal changes from treatment, surgery is often

considered. Maxillary deficiencies have been considered a reason to engage in

early growth modification (Kim et al., 1999). As an initial form of treatment,

maxillary deficiency is routinely addressed with reverse pull headgear that is

attached to the maxilla using a fixed or removable appliance (Kajiyama et al.,

2000) . Newer forms of treatment using miniplates in both the maxilla and the

mandible and intraoral elastics are beginning to emerge (Kircelli and Pektas,

2008; Singer et al., 2000; Smalley et al., 1988). These forms of treatment are

sufficient in patients with minimal to moderate skeletal discrepancies (Smalley et

al., 1988). But, they also have a failure rate of 25-30% when properly

implemented (Cornelis et al., 2007; Kuroda et al., 2007).Some have suggested

that protraction can be enhanced using adjunctive measures such as palatal

expansion (Gautam et al., 2009; Yu et al., 2007).

19
 Rapid palatal expansion is a common form of treatment during adolescence for

individuals whose upper jaw or dental arch is constricted (Haas, 1961; 1970). In order to

restore ideal occlusion, an orthodontist uses a palatal expander to widen the upper jaw.

The upper jaw consists of two bones connected to each other by fusion, called the

mid-palatine suture. With palatal expansion, this fusion is separated, therefore widening

the upper jaw. This expansion can also affect the surrounding fusions, circumaxillary

sutures, which connect the maxilla to the skull (Haas, 1970; Oppenheim, 1945). With this

potential mobilizing effect on circumaxillary sutures, rapid palatal expansion has been

used to assist the protraction of maxilla (Kim et al., 1999; Vaughn et al., 2005; Yu et al.,

2007). Whether palatal expansion significantly enhances maxillary protraction, however,

has been one of the heavily debated controversies in orthodontics in the last several

decades. Studies based on animal and mathematical models have shown that rapid palatal

expansion may disarticulate the circumaxillary sutures and enhance a forward movement

of the maxilla (Chaconas and Caputo, 1982; Gardner and Kronman, 1971a; Haas, 1973;

Wertz and Dreskin, 1977; Yu et al., 2007). Prospective studies, both on humans and

animal, however, did not show this to be true (Kim et al., 1999; Vaughn et al., 2005).

Currently, it remains unclear how maxillary protraction with and without expansion

mobilize circumaxillary sutures mechanically at the time of force application. Using

strain gages, one can examine the direct deformation between the two bone fronts of a

suture when a force is applied to it. The aim of this study was to characterize this aspect

20
of the circumaxillary sutures during acute maxillary protraction and midpalatal expansion

in an animal model.

Materials and Methods

Animal Specimens

Six fresh heads with soft tissue intact from 1 month old pigs were used in this

study. At this age, pigs are generally comparable to preadolescent humans in terms of

craniofacial maturity (Herring, 1976) and their midpalatal sutures are patent and

responsive to expansion.

Experimental procedure

Frozen pig heads were thawed overnight and a protraction appliance was

cemented the next morning. This appliance was fabricated by cementing extension arms

on the buccal surfaces of molar bands. These arms extended pass the canines. Protraction

was achieved using 5/16”, 6oz orthodontic elastics (Dentsply international, Inc., USA).

These elastics were attached to the extension arms and stretched in an anterior direction

to the desired force. To prevent from moving, the head was secured by a metal apparatus

(Fig. 2) and manual stabilization. The force was measured for each period of protraction

using Dontrix gauges. Three force levels (100g, 200g, and 500g) of protraction were

conducted with each force level repeated 3 times (8 seconds/time with 5 second rest

21
intervals), before and after expansion. Tooth borne expanders (Hyrax) or bone-borne

expanders (using TADs) were not used in this study. Based on our pilot experiments, we

found that the midpalatal suture was difficult to open using those methods and it added

the confounding factor of changes introduced by potential tooth movement. Therefore,

we manually opened the mid palatal suture using metal shims. Each shim was

8mmx35mm with 1mm of thickness. (customized by Quest technologies, Inc.,USA).The

midpalatal suture was initially exposed by using a scalpel blade. This allowed for easier

placement of the metal shims.

Strain gages were placed on the following sutures: maxillary-zygomatic(MZ),

maxillary-premaxillary(MP), maxillary-lacrimal(ML), temporal-zygomatic (TZ ), and

internasal (IN)sutures. No gauge was attached to the midpalatal suture because

displacement at this suture was visual. After the strain gages were secured in place, we

began recording the following procedure: Baseline protraction phase, expansion 1,

protraction phase1, expansion 2, and protraction phase 2. This procedure continued until

Protraction phase 5 was reached (Figure 1).

Power analysis

We assumed that suture strain magnitude caused by protraction will increase at

least 2 fold after 5mm of palatal expansion based on our assumptions. Therefore, a

sample size of six was determined based on repeated measures ANOVA, with a 3-fold

22
difference in the means and a 50% coefficient of variance. Using G*Power 3.0

calculation, a power above 90% at a 0.05 significance level could be reached.

Strain analysis

The strain magnitudes, before and after each activation of expansion and

protraction, were quantified. Strain was measured as deformation of the strain gage, and

not the suture. Strain polarity on the sutures was directly read from the strain gauge

recordings with an upward waveform indicating tension, and a downward waveform

indicating compression. The tensile value was represented by a positive value and the

compressive strain was represented by a negative value. An example is shown in Fig 4. In

this example, the average strain was measured from the black line. The red line indicates

the rest period where protraction was halted.

Statistical analysis

Mean values were compared using repeated measures ANOVAs. This statistical

method was chosen because multiple repeated measurements were taken from the same

sutures under a series of procedures in each animal. This method minimized the influence

of individual differences in animals on the variations caused by independent variables

being tested. In this study, strain was identified as the dependent variable while, both

protraction and expansion was recognized as the independent variables. A p value ≤.05 is

23
considered statistically significant, and a pvalue ≤ .001 is considered highly significant. A

pvalue ≥.05 and ≤.15 is considered a tendency towards significance but needs further

studies to verify results.

Results

Relative strain caused by protraction

Detailed relative strains caused by protractions are shown in Table 1-5

Summarized data are shown in Fig. 4. Overall, protraction force caused relatively larger

strains at the MZ sutures than the other 4 sutures tested. Protraction generally caused

tensile strain at the MZ suture and this tension increased significantly (p=0.035) with

protraction force magnitude. After palatal suture opening, however, the relative strain

caused by the same force level of protraction decreased significantly (p=0.026). The MP

suture, on the other hand, was generally in compression. Unlike the MZ suture, this

relative compressive strain at the MP suture did not change significant with the

protraction force magnitude and remained relatively constant with midpalatal suture

opening.

Overall, the IN suture was minimally effected by the protraction forces (near "0"

strains). With expansion, its strain significantly became less compressive (p=0.005). The

LM suture also showed minimal response. The TZ suture was generally in small

compression and the average magnitude demonstrated a trend to increase with force

levels (p=0.073) and did not change with palatal suture opening (p=0.169).

24
Strain caused by expansion

Summarized cumulative strains caused by expansion are presented in Fig. 5.

Overall, opening of the midpalatal suture caused larger absolute strains in all sutures than

those caused by maxillary protraction. The MZ suture was compressed during palatal

suture opening and the magnitude of compression tended to increase (p=0.145) as sutural

opening increased.

In contrast to the MZ suture, the MP suture showed tension during the opening of

the palatal suture and tension increased significantly with palatal suture opening

(p=.044).

The IN suture was compressed during palatal suture opening, and the magnitude

of compression did not increase significantly with midpalatal suture opening (p=0.218).

The LM suture showed a mixed strain pattern and the magnitude of strain did not change

with suture opening (p=0.565).

The TZ suture also showed a mixed strain pattern as well, but was generally

compressive and the magnitude of compression did not change with suture opening

(p=0.162).

Cumulative Strain caused by protraction

Detailed cumulative strains (changes from original baselines) of each tested suture

are listed in Tables 6-10. Summarized data are shown in Fig. 6. The effect of protraction

25
forces were more pronounced at sutures MZ and MP. As expected the MZ suture

displayed tension during the initial protraction when no expansion was present. The first

change was noted once the palatal suture was opened. With palatal suture opening, MZ

suture strain became increasingly compressive which was highly statistically significant

(p=.001). Strain decreased despite the counteracting tensile effect caused by protraction.

The counteracting effect was stronger when the protraction force level was higher

(p=0.062). On the other hand, the MP suture displayed reverse results. It was slightly

compressed during initial protraction. Once expansion occurred, the strain dynamics were

changed to tension and increased in magnitude with midpalatal suture opening (p<0.001),

despite the counteracting effect from protraction. As protraction forces increased, the

counteracting effect (p=0.028) increased as well. Overall, the MP suture was stained in an

opposite way to the MZ suture.

As previously stated, the protraction force had a negligible effect on IN suture. As

the protraction force increased, the IN suture remained relatively stable (p=0.591).

Although, initially stable, compression was observed as the expansion levels tended to

increase (p=0.081. The protraction had a small effect on the LM suture. It remained

relatively stable as the protraction levels increase (p=0.741). Expansion tended to change

the strain pattern from compression to tension.

Strain at the TZ suture did not have a consistent pattern. Neither protraction force

nor expansion showed any consistent effect on TZ suture strain change (p>0.05).

26
 Discussion

Circumaxillary suture strains

The terms, tension and compression, suggest positive and negative values of

means, respectively. Tension indicates widening of the suture space or separating of the

two bone fronts on either side of the suture. Compression indicates narrowing of the

suture space or converging of the two bone fronts. In this study, tensile strain was

observed during protraction at the maxillary-zygomatic suture. As a suture immediately

posterior to the maxilla, tensile strain at the maxillary-zygomatic suture indicates that the

maxilla was displaced away from the zygomatic bone. Additionally, compressive strain

was registered at the maxillary-premaxillary sutures, albeit smaller than strains at the

maxillary-zygomatic suture, indicates that the maxilla was displacing towards the

premaxilla. The protraction force has negligible effect on IN suture strain as changing the

force level did not change IN suture strain (p=0.591), suggesting the maxillary

protraction does not mobilize the sutures in the transverse direction. The LM suture

responded to the initial protractive force, but did not show much change as levels of

protraction increased. This is probably due to the location of the suture as well. Together,

these data confirmed that maxillary protraction indeed produces a mechanical tendency to

displace the maxilla forward.

In addition to revealing the direction of maxillary displacement, these strain gage

data can be extrapolated to show how much the bone fronts of a suture are actually

27
moving. By multiplying each strain by the length of the strain gage (17mm), the opening

or closing of the suture can be discovered. Overall, our recorded strain was very small.

Therefore, the actual distance the suture is opened or closed by the protraction and

expansional forces is minimal for both, MP suture (0-6.7 µm) and MZ suture (0.4-3.2

µm). These distances are unlikely to cause a large mechanical disarticulation of sutures

visible to human eyes or radiographic images.

To date, there have been three previous studies that evaluates the strain during

either protraction, expansion, or both (Holberg et al., 2007; Sun et al., 2011; Yu et al.,

2007). Sun et al. examined the strain pattern of the circumaxillary sutures during

expansion. The recorded strains in that study were substantially higher than recorded

strains in the present study. This difference may be explained by two reasons. First, the

pigs used in the present study were younger and possibly have mid palatal sutures more

patent. In these pigs, when expansion force was applied, most of it is likely being

subsided by deformation at the midpalatal suture (opening) rather than being transmitted

to adjacent sutures and hence cause less strain at these sutures. Second, the previous

study used a jackscrew appliance which was cemented on the molars. Due to the age of

the pig, little opening of the mid palatal suture was in fact accomplished by this type of

appliance. We suspect that majority of the force in the previous study was directed

towards the molars and alveolar bone, and then transmitted to the adjacent sutures

including the midpalatal suture. The location of the sutures such as the TZ suture is close

enough to the alveolar process that the effect of expansion is magnified.

28
 On the other hand, strains obtained from mathematical modeling in two other

previous studies (Holberg et al., 2007; Yu et al., 2007) was smaller than the strains that

we measured. This can be easily explained by the difference of research design among

the studies. As the data from a finite element model often need to be confirmed by actual

measurements, our results indicate that future finite element model analysis may need

adjustment of certain parameters.

Haas and Oppenheim both advocated that maxillary expansion moves the maxilla

downward and forward (Haas, 1970; Oppenheim, 1945). If they were to evaluate strain

dynamics (compression vs. tension), their results could be extrapolated to suggest that the

suture (MP) anterior to the maxilla was compressed and the suture (MZ) posterior to the

maxilla would show tension during expansion. These were the opposite of what we

found. Based on our data, at least immediately upon force application during midpalatal

suture expansion, the maxilla did not receive a mechanical tendency to move forward.

Since their theories (Haas 1970; Oppenheim 1945) were based on adolescents that were

growing, it is possible that the downward and forward movement of the maxilla that they

reported was due to a long term normal growth rather than mechanical force caused by

midpalatal expansion.

Hyung used a three-dimensional model to analyze maxillary protraction with or

without palatal expansion. With a protraction force of 500g, he measured the stress

distribution of the craniofacial bones. According to his findings, there were greater tensile

stress to the circumaxillary suture area of the maxilla and zygomatic arch when the

29
midpalatal suture was opened. He noticed the greatest stress was found in the area of the

zygomaticomaxillary suture. Our data support his results by finding the greatest strain in

the MZ suture during midpalatal suture expansion, but our data did not agree with the

pattern of strain dynamics they reported in a way that expansion assists protraction. In

general, we found that the tensile strain at the MZ suture decreased as the midpalatal

suture started to be opened and became compressive with more midpalatal suture

opening, suggesting at least based on strain dynamics, expansion seems to oppose

protraction mechanics. This was further supported by strains of the MP suture, which is

anterior to the maxilla. We found that once the midpalal suture was expanded, the

compression caused by protraction was reversed to tension, suggesting the maxilla may

have a tendency to move backward even when the protraction force was in place.

Similar results of strain dynamic patterns were found in an earlier study

performed on older pigs (3 and 6 month old) (Sun et al., 2011).Mechanical strain was

measured at similar sites and the dynamics (compression vs. tension) at the MZ and MP

sutures caused by expansion mostly agreed with the results found in this study.

Research model and method: implications and limitations

This study sought to measure immediate mechanical strains at some

circumaxillary sutures caused by maxillary protraction and midpalatal suture expansion.

This was the first study attempted for such a purpose. Because of the invasiveness of the

30
experimental procedures, an animal model was necessary. A pig model was chosen for

this study. Compared to humans, the midpalatal suture and the surrounding sutures of

pigs are similar. The overall anatomy and function of the maxillary and zygomgatic

bones are also comparable to those in humans (Herring, 1976; Strom et al., 1986) . The

long snout and the distinct premaxilla are major differences in the craniofacial anatomy

between pigs and humans. The suture between the maxilla and premaxilla fuses as early

as 3 years old in humans while fully interdigitated in pigs at that time. It is likely that

fusion between the maxilla and premaxilla may change the mechanics of the maxilla. On

the other hand, given that the premaxilla in humans is much shorter than that in pigs, the

maxilla alone in pigs may be reasonably similar to a fused maxilla-premaxilla in humans.

An unfused maxillary-premaxillary suture in pigs provided an additional benefit for this

study because it allowed us to attach a strain gage to it so the displacement pattern of the

maxilla can be observed from both anterior and posterior aspects.

In this study, dead, but well preserved pig specimens were used, which differed

from clinical procedures. In living animals and humans, sutures not only consist of

fibrous tissue, but cellular elements, as well. Undoubtedly, the biological characteristics

and function of these elements can only be shown in a live being. While the use of dead

animal tissue in this study would not be able to reflect the biological aspect of these

sutures, the preservation of the anatomy, collagenous and water content of the sutures

allowed a reasonable reflection of their deformation when mechanical force was applied.

This study focused on the immediate mechanical portion of these sutures with an

31
understanding that the long-term responses, especially on the biological side, may

substantially differ.

Our expansion technique was different than clinical practice on human patients.

Clinically, a jackscrew is fabricated and cemented to maxillary first molars and

sometimes, the first premolars as well. The jack screw appliance is usually activated once

or twice per day for fourteen days to give a total of 3-7 millimeters of expansion. In this

study, we used a scalpel for initial access to the suture, followed by inserting metal shims

of standard thickness into the mid-palatal suture to expand it. This was chosen instead of

a jack screw expander typically used on human patients. This choice was made based on

our pilot studies which found that both tooth borne (jackscrews) and bone borne

(temporary anchorage screws) types expanders failed to open the pig midpalatal suture.

This failure was probably due to the fact that the pig palatal bone is relatively thin at this

age. In our study, we expanded, with the placement of metal shims, after each level of

protraction producing a total of 5mm of expansion. This process occurred in a matter of

minutes. While this expansion protocol was certainly different than a clinical one, it

allowed us to understand the mechanical deformation immediately when the midpalatal

suture was open.

Our protraction technique was also somewhat different than clinical practice.

Clinically, if expansion is needed due to crowding or posterior crossbite, the jackscrew

expander is activated once per day until desired expansion results are achieved. If the

patient does not need expansion, the expander is activated, usually once a day for 7 to 10

32
days before the start of protraction. A face mask (Fig. 7) is then delivered to the patient

with bilateral 3/8-inch, 8-ounce elastics. This force magnitude is typically used for the

first few weeks of treatment for patient comfort. After that, the force is increased with

the use of 1/2-inch, 14-ounce elastics or even 5/16-inch, 14-ounce elastics. The direction

of elastic traction is forward and downward. Elastics are attached to the hooks on the

maxillary expander and to the adjustable crossbar of the facial mask. Patients are asked to

wear it for as much as possible but at least 12 hours a day (Vaughn, Mason et al. 2005).

In this acute study, as our focus was on immediate mechanical response at the

circumaxillary sutures, such a clinical protocol was not used. Nevertheless, by registering

strains during protraction before and after midpalatal suture expansion, we were able to

understand the immediate mechanical impact of palatal suture expansion on protraction.

In summary, according to our results, expansion did not seem to enhance the

protractive forces at the time when forces were applied. Our study did not evaluate the

biological aspect of the sutures, nor investigate the mechanical strain caused by a long

term expansion/protraction protocol; these findings should not be directly applied to

clinical situations.

Conclusion

The opening of the midpalatal suture produces stronger strains at the anterior and

posterior circumaxillary sutures than those created by maxillary protraction. The pattern

of strain dynamics (compression or tension) at the anterior and posterior circumaxillary

33
sutures produced by midpalatal suture opening was also opposite to those produced by

maxillary protraction. These suggest that the immediate mechanical effect caused by

midpalatal suture opening may counteract maxillary protraction mechanics. In order to

make these findings clinically applicable, further studies need to be conducted based on

clinical expansion and protraction protocol in a live animal model.

34
 List of Tables

Table 1. Relative strain measurements at the MZ caused by protraction

Strain measurements are listed for every level of protraction after each millimeter of
expansion. Each row represents data from one animal under certain protraction force.

MZ
Expansion suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g 19.2 13.1 37.4 20.6 23.9 25.0
38.3 16.5 10.0 8.0 10.2 20.4
3.0 2.6 2.3 -0.1 1.8 1.8
34.4 14.8 50.8 33.2 23.6 22.1
42.1 3.8 5.8 1.1 7.7 2.2
40.5 29.6 28.1 15.2 12.5 11.4

250g 67.2 44.5 48.6 35.4 36.8 37.6

115.1 50.3 20.2 14.7 15.5 11.3
4.7 5.8 4.6 3.9 4.3 3.8
109.4 85.0 76.3 62.4 69.8 59.0
50.9 9.5 8.1 -2.2 4.8 11.7
133.2 76.7 59.6 23.4 35.0 5.0

500g 106.1 82.6 73.5 107.7 94.6 63.1

143.7 68.1 31.4 7.5 14.4 23.4
-0.2 1.3 6.4 11.9 1.8 4.4
199.9 138.9 151.9 130.1 144.5 125.7
67.9 52.5 34.5 31.5 22.3 5.8
252.4 176.9 179.0 129.6 123.7 63.6

35
Table 2. Relative strain measurements at the MP suture caused by protraction
Strain measurements are listed for every level of protraction after each millimeter of
expansion. Each row represents data from one animal under certain protraction force.

MP
Expansion suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -0.3 10.9 43.2 70.9 80.7 83.0
-0.9 323.1 592.3 796.5 882.3 1191.8
-2.7 200.4 433.5 717.7 321.1 479.2
-3.1 122.5 139.5 216.1 189.2 190.8
-9.7 403.0 484.8 352.0 359.3 685.4
-4.3 260.2 384.2 447.9 449.0 542.2

250g -1.1 11.9 43.4 69.5 81.2 85.1

2.7 322.4 552.5 786.0 879.7 1191.7
-3.3 182.9 421.1 709.4 297.5 457.7
0.5 108.3 126.8 209.0 176.0 189.1
-17.1 384.9 456.8 337.5 331.1 661.6
-5.2 238.0 356.0 429.6 429.8 531.0

500g 0.2 21.7 39.8 64.9 83.4 78.4

14.2 317.3 531.6 765.3 860.1 1173.3
-2.7 174.2 405.7 663.5 278.9 441.5
25.2 134.9 117.3 204.2 158.5 173.5
-15.9 339.2 413.1 308.3 290.6 627.9
3.1 192.7 330.7 393.7 394.8 509.9

36
Table 3. Relative strain measurements at the TZ suture caused by protraction
Strain measurements are listed for every level of protraction after each millimeter of
expansion.

TZ
Expansion suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -3.1 -2.4 -8.6 -7.2 -5.6 -6.6
2.4 -0.6 -2.7 -7.6 -6.5 -27.6
-9.4 -3.8 -1.3 2.1 -5.9 -9.8
-9.6 -4.9 -15.1 -14.2 -11.3 -9.2
-5.3 -17.5 -15.4 2.7 2.9 3.7
-2.0 -3.0 7.2 -2.1 -6.4 -3.0

250g -8.1 -3.7 -2.9 -3.9 -1.5 -7.2

1.5 -0.3 -8.4 -23.9 -10.3 -17.8
-34.4 -11.5 0.2 -2.8 -16.8 -16.0
-32.3 -19.9 -24.6 -24.2 -22.7 -25.8
-6.1 -8.0 -16.8 -7.4 -6.6 -7.6
-17.0 -3.0 8.9 -1.6 2.4 -1.5

500g -21.2 -12.6 -2.3 -12.4 -1.6 -7.7

-12.9 -34.2 -18.8 -5.7 -11.5 -23.2
-52.0 -33.3 -16.8 -38.7 -5.1 -32.4
-74.7 -51.1 -52.2 -35.8 -48.8 -36.4
-9.0 -2.6 -31.9 7.0 2.1 3.2
-26.8 -5.6 0.6 13.9 21.2 7.2

37
Table 4. Relative strain measurements at the IN suture caused by protraction
Strain measurements are listed for every level of protraction after each millimeter of
expansion.

Expansion IN suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -0.8 -2.2 -1.7 -1.8 -1.3 -0.9
2.7 -1.3 -2.3 -1.3 -0.5 0.6
-3.8 -3.7 -1.0 -1.1 -1.0 2.5
-0.6 0.5 2.7 0.8 -4.4 -0.6
-2.4 -0.1 -2.7 -1.4 -2.4 -1.3
-4.4 0.3 -0.1 -1.9 -2.1 -1.2

250g -4.6 -5.4 -3.6 -3.3 -2.4 -3.2

-0.4 -0.2 -3.1 -2.7 -1.1 -0.2
-5.7 -1.7 -1.3 -1.6 -1.0 -2.0
-0.5 1.3 2.3 2.1 0.6 -0.1
-3.2 0.1 -2.7 -1.0 -3.2 -2.0
-12.4 -3.2 -1.4 -0.6 -1.3 -2.4

500g -7.1 -3.9 -8.5 -2.1 -0.7 -2.9

-5.6 7.0 -3.3 -0.2 0.9 1.1
0.1 12.6 -1.5 4.8 -1.8 -1.7
2.8 3.7 3.1 2.3 4.1 1.4
-6.0 2.2 0.2 -2.9 -1.8 -1.4
-6.5 -4.2 -7.6 -7.1 -4.3 -5.3

38
Table 5. Relative strain measurements at the LM suture caused by protraction
Strain measurements are listed for every level of protraction after each millimeter of
expansion.

Expansion LM
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g 0.4 -1.4 -8.9 0.8 1.5 3.6
-30.5 -9.5 -5.0 1.2 0.8 -4.3
-8.2 -11.8 2.1 -4.2 2.0 -2.0
-14.7 -5.6 -13.0 -6.6 -5.7 -7.5
-22.7 -2.9 9.4 -0.9 -1.6 -11.0
4.0 2.4 3.8 4.9 8.7 6.1

250g -2.2 -5.4 -2.5 -2.4 -2.6 -0.1

-55.3 -14.4 -9.6 -0.8 -3.9 -0.2
-18.2 -18.3 -7.9 -12.7 2.2 -3.1
-17.8 -13.8 -13.9 -17.1 -15.1 -19.5
-19.8 -12.0 13.1 -9.2 -18.1 -7.4
-2.9 5.0 3.8 11.5 13.5 14.8

500g -14.7 -6.9 -12.7 3.2 5.0 6.9

-35.5 -12.3 -12.6 4.9 -2.7 -2.1
-23.7 -7.8 -23.7 -37.8 -0.5 -4.2
-29.4 -26.2 -28.4 -25.3 -28.7 -32.2
-22.5 -23.0 -24.8 -20.5 -39.2 -42.9
10.7 14.6 16.6 31.4 29.0 28.2

39
Table 6. Cumulative strain measurements at the MZ suture during protraction (from
original baseline measurement) Strain measurements are listed for every level of
protraction after each millimeter of expansion.

Expansion MZ
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g 19.2 -86.2 74.1 -20.2 -304.1 -477.6
38.3 -32.0 -22.5 -120.0 -184.6 -106.5
3.0 -29.7 -48.8 -32.1 19.9 16.3
34.4 -11.2 -4.7 -105.2 -79.7 -118.2
42.1 -230.0 -269.3 -208.9 -248.2 -330.1
40.5 -168.8 -265.2 -337.2 -405.1 -483.1

250g 67.2 -44.8 144.3 15.1 -262.0 -438.0

115.1 3.2 -22.4 -106.8 -178.8 -105.1
4.7 -30.5 -40.8 -26.9 21.6 18.6
109.4 11.4 31.0 -81.1 -44.3 -103.1
50.9 -259.1 -293.9 -236.2 -240.2 -319.4
133.2 -110.8 -224.2 -322.0 -372.1 -481.7

500g 106.1 23.2 115.2 152.2 -174.1 -334.9

143.7 -13.9 -61.7 -162.2 -223.6 -147.5
-0.2 -11.5 -43.6 -1.3 11.2 19.1
199.9 55.9 51.7 -62.8 -25.4 -79.0
67.9 -216.8 -249.6 -224.7 -237.5 -360.1
252.4 -78.8 -236.2 -331.0 -413.1 -564.9

40
Table 7. Cumulative strain measurements at the MP suture during protraction (from
original baseline measurement). Strain measurements are listed for every level of
protraction after each millimeter of expansion.

Expansion MP
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -0.3 10.9 43.2 70.9 80.7 83.0
-0.9 323.1 592.3 796.5 882.3 1191.8
-2.7 200.4 433.5 717.7 321.1 479.2
-3.1 122.5 139.5 216.1 189.2 190.8
-9.7 403.0 484.8 352.0 359.3 685.4
-4.3 260.2 384.2 447.9 449.0 542.2

250g -1.1 11.9 43.4 69.5 81.2 85.1

2.7 322.4 552.5 786.0 879.7 1191.7
-3.3 182.9 421.1 709.4 297.5 457.7
0.5 108.3 126.8 209.0 176.0 189.1
-17.1 384.9 456.8 337.5 331.1 661.6
-5.2 238.0 356.0 429.6 429.8 531.0

500g 0.2 21.7 39.8 64.9 83.4 78.4

14.2 317.3 531.6 765.3 860.1 1173.3
-2.7 174.2 405.7 663.5 278.9 441.5
25.2 134.9 117.3 204.2 158.5 173.5
-15.9 339.2 413.1 308.3 290.6 627.9
3.1 192.7 330.7 393.7 394.8 509.9

41
Table 8. Cumulative strain measurements at the TZ suture during protraction (from
original baseline measurement. Strain measurements are listed for every level of
protraction after each millimeter of expansion.

Expansion TZ
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -3.1 21.7 52.2 32.4 -16.3 -43.4
2.4 -33.3 -22.4 -79.8 -206.1 -253.5
-9.4 -69.2 1.3 -15.2 -7.0 5.0
-9.6 15.4 23.3 35.6 14.7 26.4
-5.3 35.2 99.2 108.4 111.3 97.7
-2.0 8.1 35.1 30.1 1.1 -7.1

250g -8.1 16.3 28.5 30.1 -17.9 -61.2

1.5 -35.0 -42.0 -128.5 -232.3 -269.8
-34.4 -28.6 3.2 -5.3 -4.9 10.7
-32.3 1.2 0.7 17.5 2.3 8.3
-6.1 23.2 52.8 76.8 68.8 44.4
-17.0 -2.3 38.8 27.7 0.9 -9.7

500g -21.2 13.7 50.8 17.2 -14.8 -82.9

-12.9 -73.8 -66.5 -145.4 -227.6 -279.8
-52.0 -79.7 22.6 -37.1 32.5 12.1
-74.7 -1.3 14.1 55.0 21.0 57.1
-9.0 -25.9 -34.4 68.8 41.6 -2.7
-26.8 39.5 41.9 66.6 26.1 -3.6

42
Table 9. Cumulative strain measurements at the LM suture during protraction (from
original baseline measurement. Strain measurements are listed for every level of
protraction after each millimeter of expansion.

Expansion LM
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g 0.4 -49.5 -2.2 -39.8 16.8 -52.2
-30.5 -5.1 17.7 -10.3 5.4 -67.3
-8.2 17.6 -27.1 -98.5 -15.4 25.8
-14.7 -45.0 -20.0 -10.3 16.3 27.4
-22.7 53.1 62.4 125.7 201.3 136.1
4.0 -10.2 10.5 14.7 67.0 67.3

250g -2.2 -50.9 -5.2 -36.1 17.3 -44.0

-55.3 1.5 19.1 16.8 8.4 -67.3
-18.2 -2.8 -57.9 -124.0 -13.8 19.8
-17.8 -35.7 -11.7 -8.4 21.4 22.5
-19.8 49.9 74.0 120.0 184.6 134.9
-2.9 6.3 25.1 39.5 89.6 92.8

500g -14.7 -38.8 -12.7 2.1 45.8 18.4

-35.5 -3.7 7.5 4.2 12.5 -40.6
-23.7 -13.2 -91.1 -171.0 -57.0 -26.8
-29.4 -65.5 -27.6 -29.2 -2.9 2.5
-22.5 8.2 6.6 94.1 144.9 85.8
10.7 29.3 58.0 90.6 127.2 133.0

43
Table 10. Cumulative strain measurements at the IN suture during protraction (from
original baseline measurement. Strain measurements are listed for every level of
protraction after each millimeter of expansion.

Expansion IN
suture
Protraction 0 1mm 2mm 3mm 4mm 5mm
100g -0.8 -3.6 -44.2 -82.7 -102.0 -135.1
2.7 -30.0 -109.2 -264.2 -484.7 -485.4
-3.8 -48.7 -104.1 -160.8 -68.7 -90.5
-0.6 -13.6 -21.2 -27.7 23.2 -41.4
-2.4 -45.1 -70.2 -25.6 -61.4 -100.7
-4.4 -105.5 -103.9 -141.5 -168.0 -248.6

250g -4.6 -13.6 -47.3 -88.8 -106.6 -139.6

-0.4 -33.4 -117.4 -271.6 -488.7 -485.3
-5.7 -54.5 -108.3 -170.6 -74.5 -115.2
-0.5 -14.5 -15.7 -21.4 9.8 -43.2
-3.2 -42.3 -70.4 -23.8 -70.5 -109.0
-12.4 -95.9 -94.5 -133.8 -162.0 -239.2

500g -7.1 -21.6 -51.0 -88.6 -103.6 -134.8

-5.6 -26.3 -120.6 -269.5 -450.4 -474.9
0.1 -90.1 -112.9 -171.8 -78.5 -129.0
2.8 -7.6 -11.6 -14.7 -2.4 -44.4
-6.0 -31.2 -57.0 -27.6 -68.5 -115.4
-6.5 -70.8 -79.2 -126.5 -150.0 -225.9

44
 List of Figures

Figure 1. Experimental procedure

45
Figure 2. Apparatus used to stabilize pig cadaver heads

46
Figure 3. Suture sites for strain measurement. One perpendicular strain gage was placed
at each of the labeled sites.

47
Figure 4. Strain recording analysis. Each horizontal bar represents the strain at that
particular suture (MP –premaxilla, TZ-temporal zygomatic, LM-lacrimal maxillary, MZ-
zygomatic maxillary, IN- internasal).The black arrow displays a period of protraction.
The length of the arrow signifies the duration of the protraction. The red arrow displays a
resting period. Relative strain for this protraction cycle was calculated by subtracting the
mean value of the resting phase from the mean value of the protraction phase.

48
Figure 5. Relative strain caused by protraction. Each graph displays total strain at
each suture. Each bar within the graph represents standard error

49
Figure 6. Cumulative strain caused by expansion strain. Each graph displays total
strain after each millimeter of expansion. Each bar within the graph represents standard
error.

50
Figure 7. Cumulative strain caused by protraction from the start of the experiment.
Each graph displays total strain at each suture. Each bar within the graph represents
standard error.

51
Figure 8. Protraction facemask for humans.

52
 Chapter 4: Conclusions

Compared to maxillary protraction, opening of the midpalatal suture generates

stronger but opposite strains at anterior and posterior circumaxillary sutures, suggesting
that the immediate mechanical effect caused by midpalatal suture opening may
counteract maxillary protraction mechanics.

53
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