Journal Pre-proof

The role of pediatric maxillary expansion on nasal breathing. A systematic review and
metanalysis

Christian Calvo-Henriquez, Robson Capasso, Carlos Chiesa-Estomba, Stanley Yung

Liu, Silvia Martins-Neves, Elena Castedo, Carlos O’Connor-Reina, Alberto Ruano-
Ravina, Sandra Kahn
PII: S0165-5876(20)30282-2
DOI: https://doi.org/10.1016/j.ijporl.2020.110139
Reference: PEDOT 110139

To appear in: International Journal of Pediatric Otorhinolaryngology

Received Date: 26 March 2020

Revised Date: 21 May 2020
Accepted Date: 22 May 2020

Please cite this article as: C. Calvo-Henriquez, R. Capasso, C. Chiesa-Estomba, S.Y. Liu, S. Martins-
Neves, E. Castedo, C. O’Connor-Reina, A. Ruano-Ravina, S. Kahn, The role of pediatric maxillary
expansion on nasal breathing. A systematic review and metanalysis, International Journal of Pediatric
Otorhinolaryngology, https://doi.org/10.1016/j.ijporl.2020.110139.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Published by Elsevier B.V.

 Article Title: The role of pediatric maxillary expansion on nasal
breathing. A systematic review and metanalysis.

Running Title: pediatric maxillary expansion and nasal breathing

Authors: Christian Calvo-Henriquez MD1,2; Robson Capasso MD PhD3;

Carlos Chiesa-Estomba MD1,4; Stanley Yung Liu MD, DDS3; Silvia Martins-
Neves DDS5; Elena Castedo DDS6; Carlos O’Connor-Reina MD PhD7; Alberto
Ruano-Ravina PhD8,9; Sandra Kahn DDS10.

Authors’ Affiliations:
(1) Young-Otolaryngologists of the International Federations of Oto-
rhino-laryngological Societies (YO-IFOS) study group.
(2) Service of Otolaryngology. Hospital Complex of Santiago de
Compostela, Spain.
(3) Department of Otolaryngology - Head and Neck Surgery, Sleep
Surgery Division, Stanford University Medical Center, Stanford, CA USA.
(4) Service of Otolaryngology. Donostia University Hospital, San
Sebastian - Spain
(5) Department of orthodontics. My Face Clinics and Academy, Lisbon–
Portugal
(6) Orthodontic private practice. Santiago de Compostela, Spain.
(7) Service of Otolaryngology. Hospital QuironSalud Marbella. Marbella,
Spain.
(8) Department of Preventive Medicine and Public Health. University of
Santiago de Compostela. Spain.
(9) CIBER de Epidemiología y Salud Pública. CIBERESP, Spain
10) Private Practice. San Francisco, CA USA.

Financial support: There is no financial support.

Conflict of interest: The authors declare not to have any conflict of
interest.

1 Address: Christian Calvo-Henriquez. Service of Otolaryngology.

Hospital Complex of Santiago de Compostela. Travesía de Choupana, s/n.
15706 Santiago de Compostela. Spain. Telephone number: +34-981-951155.
E-mail: christian.calvo.henriquez@gmail.com

1
 The role of pediatric maxillary expansion on nasal
breathing. A systematic review and metanalysis.

ABSTRACT

OBJECTIVE: A reduced transversal dimension of the maxilla leads to narrower

nasal cavities, which may reduce airflow to the lungs. Maxillary expansion
widens nasal floor. However, there is huge controversy regarding whether this
increase does actually lead to increased airflow. In this systematic review and
meta-analysis we aim to resolve this question by evaluating studies that have
undertaken rhinomanometric measurements.
REVIEW METHODS: Pubmed (Medline), the Cochrane Library, EMBASE and
Trip Database were checked by two authors. Two authors extracted the data.
Main outcome was expressed as the difference between resistance before and
after treatment and the 95% confidence interval.
RESULTS: 30 studies were selected for full text reading. A total of 12 studies
(301 patients) met the inclusion criteria. All selected articles found reduced
resistance after palatal expansion. The data pooled in the meta-analysis reveals
a statistically significant difference of 0.12 Pa s/cm3 mean reduction after palatal
expansion (CI 95% 0.06, 0.18) for nine uncontrolled studies. Regarding nasal
airflow, the pooled data show a statistically significant difference of 29.9 cm3/s
increase after palatal expansion (CI 95% 9.17, 50.64)
CONCLUSION: According to the available evidence, palatal expansion in
pediatric patients decreases nasal resistance and increases nasal flow.

KEYWORDS: rapid palatal expansion; rapid maxillary expansion;

rhinomanometry; RPE; RME.

1
 INTRODUCTION
Proper nasal breathing in children is of paramount importance in order
to ensure the adequate growth and development of the craniofacial complex.1
Impaired nasal breathing is frequently associated with maxillary constriction,
some authors reporting this link in up to 47% of cases.2
Maxillary constriction makes reference to a narrowing of the upper jaw,
which is commonly accompanied by a posterior crossbite, high palatal vault
with the consequent elevation of the nasal floor.3 It is one of the most frequent
skeletal problems in the craniofacial region, with prevalence ranging from 2.7 to
23.3% in patients under 18 years of age.4
Some researchers found a logical correlation between impaired nasal
breathing and maxillary constriction, each being both cause and consequence of
the other. Impaired nasal breathing forces an open mouth posture, which may
lead to maxillary constriction. Conversely, since a reduced transversal maxilla
leads to a narrower dimension of the nasal cavities, it may cause impaired
breathing.
Maxillary expansion (ME) is a common treatment to widen narrow
maxillae. It is a distraction procedure that splits the mid-palatal suture to
encourage the growth of the maxilla along the suture. The treatment is typically
carried out with a device which includes an expansion screw welded to bands
on first molars. When the maxillary dental arch is expanded, the maxillary and
palatine bones disarticulate along the mid-palatal suture and move laterally so
that part of the lateral nasal walls is shifted outward producing a small increase
of transalar width.
It is generally huge in medical literature that ME promotes the widening
of the nasal floor and improves the distance between the nasal walls and the
septum, thus providing an overall increase in the dimensions of the nasal
cavity.5 However, there is huge controversy regarding whether this increase
does actually lead to a reduction in airflow resistance. Since the first organized
reports on this topic were published in the 1960s,6 several researchers have tried
to address this question.
An objective test is needed, since primary school children often
underestimate their nasal obstruction.7 The most accepted method for
measuring nasal resistance is rhinomanometry. It is an objective method to
study nasal physiology, which involves taking measurements of nasal airflow
and differences in pressure. It can be mathematically converted to nasal airway
resistance as the quotient of the difference in pressure and the flow.
In this systematic review and meta-analysis, we aim to solve the question
of whether maxillary expansion in pediatric patients reduces nasal resistance,
confirmed by undertaking a rhinomanometric study.

2
 METHODS
This review was performed in accordance with PRISMA guidelines, and
a formal PROSPERO protocol was published according to the NHS
International Prospective Register of Systematic Review (Nº 157516) prior to the
review being conducted. Also, we followed the recommendations of the
AMSTAR-2 guideline.8

Literature Search. Inclusion and exclusion criteria

The criteria for considering studies for the systematic review were based
on the population, intervention, comparison, and outcome (PICOS)
framework.9
Participants: Pediatric patients under eighteen years of age.
Intervention: We explored the effects of maxillary expansion.
Comparison: pre- and post-treatment data (case series), or treatment and
no treatment cohorts (cohorts and clinical trials).
Outcomes: We measured the outcomes by rhinomanometric changes in
inspiration (flow and resistance).
Types of studies: Clinical trials, case series, prospective and
retrospective cohort studies published in peer-reviewed journals. We did not
include case reports, thesis or meeting communications. There were no
restrictions by date or publication type, and the last update of the search was
performed in Dec 2019. We included studies published in English, Spanish,
German, French, Italian and Portuguese.

Exclusion criteria: exclusion criteria consisted of: 1) studies on

syndromic patients; 2) dual publications; 3) studies in adults without individual
analysis of the pediatric sample; 4) articles in which a further nasal intervention
was carried out between the first and second rhinomanometric explorations; 5)
studies in which rhinomanometry was not performed; 6) studies in which
rhinomanometry was performed but analysis between groups was not
conducted.

Search strategy

We followed the recommendations of the PRISMA statement for

performing systematic reviews and searched Pubmed (Medline), the Cochrane
Library, EMBASE, Scopus, Science direct, SciELO and Trip Database. We used a
predefined search strategy employing a combination of the following keywords
([“maxillary expansion” OR “palatal expansion” OR “RPE” OR “RME” OR
“maxillary disjunction” OR “palatal disjunction”] AND nasal). The abstracts of
the papers retrieved were thoroughly reviewed by two authors (CCH, CCE),

3
and those potentially fulfilling inclusion criteria were full-text read. Whenever
differences in the judgement of eligibility arose, full texts were included for
final assessment. We also manually reviewed the reference listings of all
selected articles so as to identify works which might have been overlooked in
the initial search.

Study Extraction, Categorization, and Analysis

Two authors (CCH, CCE) analyzed the articles that met the inclusion
criteria in duplicate. Variables assessed included sample size, age, indication for
treatment, presence of control group, type of expander used, use of
decongestant, follow-up period and main outcome. Main outcome was
expressed as the difference between resistance before and after treatment and
the 95% confidence interval. When there was a control sample it was expressed
as the mean difference between control and cases. Flow was expressed in
cm3/sec; resistance in Pa s/cm3.

Assessment of study quality

We assessed the selected articles for both their level of evidence and
quality. Level of evidence was classified according to the Oxford Centre for
Evidence-Based Medicine Levels. Level 1a symbolized a Systematic review (SR)
of randomized trials (RCT); level 1b, Individual good quality RCT; level 2a, SR
of cohort studies; level 2b, Individual cohort study and low quality RCT; level
2c, Ecological studies; level 3a, SR of case-control studies; level 3b, Individual
case-control study; level 4, Case series and poor quality case-control and cohort
studies; level 5, expert opinion.

The risk of bias was assessed according to the Quality Assessment of case
series studies checklist from the National Institute for Health and Clinical
Excellence:10 1) Was the case series collected in more than one center? 2) Is the
hypothesis/aim/objective of the study clearly described? 3) Are the inclusion
and exclusion criteria clearly reported? 4) Is there a clear definition of the
outcomes reported? 5) Were data collected prospectively? 6) Is there an explicit
statement that patients were recruited consecutively? 7) Are the main findings
of the study clearly described? 8) Are outcomes stratified?

In order to assess the quality of the design, we developed a score prior to

full text reading, based on the score published by Lagravere et al.11 The scale
with the scoring of each item is shown in Table 1. It has 6 items with a total
score range from 0 to 120 points. The items considered were the following:
sample size; percentage of participants lost to follow-up; time to follow-up;
4
control group; use of decongestant and control of confounding factors. Papers
were independently evaluated by two authors (CCH, CCE) and disagreements
were settled through discussion. Two items have the largest weight in the
quality score assessment: control of confounding factors and use of
decongestant. There are several factors potentially influencing nose breathing.
Some are hardly variable in the period of study, such as septal deviation or
adenoids. Others are highly variable such as allergy, turbinate hypertrophy and
nasal polyps among others. The above-mentioned two items allow control of
these factors. For the control group item, we considered as a comparable control
group a cohort with similar characteristics to those of the intervention group,
which had to be followed and explored in the same way as the intervention
group but without receiving treatment.

Statistical analysis

All statistical data were analyzed with STATA for Macintosh v. 15.1
(StataCorp ®). Significance was considered with a P value < 0.05.

We used the Cochrane Collaboration’s Review Manager Software

(REVMAN) version 5.3 (Nordic Cochrane Centre, Cochrane Collaboration,
2014, Copenhagen, Denmark) to conduct the meta-analysis. The heterogeneity
was checked using the Q-test and I2 test. A fixed effects model was used when
a I2 value was <50%, and a random effects model when it was ≥50%. Finally,
the publication bias was assessed by a funnel plot and Egger regression.

5
 3 – RESULTS

Search results

A flowchart of the search process is shown in Figure 1. The initial search

retrieved 1456 publications. After reading all titles and abstracts, 30 studies
were selected for full text reading. A total of 12 studies (301 patients) met the
inclusion criteria.
Of the papers selected for full-text reading, 18 publications were excluded
for the following reasons: three were dual publication;12–14 eight were studies in
which rhinomanometry was not performed;15–22 two included adults without
subgroup analysis;23,24 and four were studies for which rhinomanometry was
performed but authors did not perform analysis between groups.25–29
Three authors had to be contacted to provide additional data for the
meta-analysis13,30,31.

Results of the included studies

General results

The mean age was 9.36, 8.75 adjusted by sample size. The lowest mean
age was reported by Monini et al (7.85 years), the highest by Halicioğlu K (12.89
years).
Regarding follow-up periods, the mean studies was 9.29 months, and
9.47 when adjusted by sample size: the lowest by Wertz et al,32 and Bazargani et
al (0 months)33, and the highest by Langer MR et al,31 and Matsumoto MR et al
(30 months)34.
All articles had an indication for treatment made by orthodontic
specialists. Only Compadretti et al reported a primary otolaryngologic
indication for the inclusion criteria.30
All the articles used rapid expansion protocols. There were no results for
slow expansion protocols.
The highest sample size was reported by Monini et al (66 patients),35 and
Compadretti et al (51 subjects).30 These are also the studies with the highest
quality score.

Nasal airway resistance

Resistance was assessed in eleven studies. All selected articles found a

positive difference for resistance after palatal expansion. However, confidence
intervals were statistically significant only for six studies.
The data was pooled in two different subgroups for the meta-analysis.
The quasi-experimental group included 9 studies and reveals a statistically
significant difference of 0.12 Pa s/cm3 mean reduction after palatal expansion
6
(CI 95% 0.06, 0.18) (Figure 2). The controlled group included 2 studies and
reveals a non-statistically significant difference of 0.02 Pa s/cm3 mean reduction
after palatal expansion (CI 95% -0.03, 0.07) (Figure 2).
Four authors had performed a rhinomanometric assessment of nasal
resistance with nasal decongestion.30,33,36,37 Three of them were not controlled,
while one was controlled and could not be included in the metanalysis. A
subgroup analysis of these papers shows a non-significant difference of 0.08 Pa
s/cm3 mean reduction after palatal expansion (CI 95% -0.01, 0.17) (Figure 3).

Nasal airflow

Nasal airflow difference after palatal expansion was assessed in three

studies,32,33,35 with a total sample of 81 subjects. Note that the sample of
Bazargani et al is divided, since the intervention was different among groups as
is in Wertz et al because the outcome assessment was also different among
groups.
Under a fixed effects model, the pooled data shows a statistically
significant difference of 29.9 cm3/s increase after palatal expansion (CI 95%
9.17, 50.64) (Figure 4).

Level of evidence and quality of included studies

According to the Oxford Center for Evidence Based Medicine

classification,38 all the studies are Level 4, with the exception of three. Those
three papers were clinical trials. According to their quality score they were
classified as Level 1b (one)30 and level 2b (two).33,39
Regarding the quality score, only Compadretti et al scored over 100
30
points and the mean quality score was 40 points (from 120), which is low.

Publication bias and small study bias

The funnel plot and Egger regression test indicate a risk for publication
bias (P=0.07) (Figure 5).

7
 4 – DISCUSSION
To the best of our knowledge this is the first systematic review and meta-
analysis on this topic although there have been reviews published about it.40–44
According to a recent review of all the available systematic reviews regarding
the relationship between nose and palatal expansion there are no high-quality
reviews made public regarding this issue.45
This systematic review and meta-analysis revealed two main findings.
First, palatal expansion in the pediatric population has been shown in
uncontrolled studies to significantly reduce nasal resistance. A comparison of
the difference in nasal resistance between pre and post palatal expansion
demonstrated a reduction by 0.12 Pa s/cm3.
Second, palatal expansion in children id followed by a 29.90 cm3/s
increase in nasal flow after treatment.

Nasal resistance

The clinical relevance of those findings depends on normal

rhinomanometric values and initial nasal resistance. Normal values change
with age,46 which makes it difficult to stablish their clinical significance. In
adults, normal values are 0.3 Pa s/cm3; in children, 0.4 is thought to be the limit
for normality.46 According to these values, a reduction of 0.12 Pa s/cm3 is
clinically relevant.
Several methods have been published trying to measure nasal outcomes
after palatal expansion. We decided to only include papers in which nasal
function was evaluated with rhinomanometry. Despite it is far away from being
perfect, rhinomanometry is considered the Gold Standard method, some it is
objective and consists of clear and protocolized measurements.47 The rest of the
methods used (cephalometry, acoustic rhinometry, CT scan, and others) focus
on anatomical changes, but not on function. Fluid dynamic simulation is closer
in evaluating function; however, it is only an approximation.
In fact, all of these measures are surrogates for what clinicians would
really like to know, which is: will nasal expansion help correct impaired nasal
breathing? Anatomical variations, despite being related to functional outcomes,
do not answer this question.

Confounding factors

The great problem among the papers trying to answer the research
question of whether maxillary expansion reduces nasal resistance is that the
selection of the sample is not appropriate in order to answer it, because of
having used the orthodontic indication as the selection criteria. The sample
must only be different in regard to expansion. However, most authors did not
control confounding factors such as turbinate hypertrophy, which is highly
prevalent among these patients.
8
 Maxillary constriction is associated with impaired nasal breathing for
other causes. Therefore, if those causes have not been previously treated, they
will continue taking place, such as turbinate and adenoid hypertrophy. For
example, Matsumoto et al found turbinate hypertrophy in 75.86% of their
patients, and adenoid hypertrophy in 44.82%; and Langer et al reported an 80%
of patients suffering from turbinate hypertrophy.31
Any factor which impairs nasal breathing is an important confounding
factor that can clearly influence the outcome being assessed. Therefore, if
researchers do not control them, we cannot arrive at solid conclusions. It is as if
we tried to assess the effects of smoking on hypertension, but we do not
consider weight control, coffee intake or exercise, for example.
Under this scope, six authors found statistically significant differences
for nasal resistance. Regarding the studies which did not find any, most of them
had either not studied confounding factors, or reported a high risk of
confounding factors. They had neither included decongestant, nor performed a
subgroup analysis. In fact, most authors who did not find any differences
attributed this fact to the possible influence of turbinate hypertrophy.28,31,34,48
It is noteworthy that Compadretti et al. do not have a statistically
significant confidence interval.30 However, in their study they affirm that the
differences are statistically significant. It could be attributed to an error in the
reported standard deviation, which is extraordinarily large compared to other
authors.

Indication for treatment

All selected papers have an orthodontic indication for the maxillary

expansion. Compadretti et al is the only selected paper with a primary
otolaryngologic indication for patients with impaired nasal breathing with no
other causes apart from maxillary constriction.
Only selecting children with orthodontic indication but no impaired
nasal breathing may induce a selection bias.
According to Hartgerink et al,23 Compadretti et al,30 and White et al,37
patients who show greater increase in nasal resistance are those who previously
suffered impaired nasal breathing. In fact, White et al found a high correlation
(R=0.9) between previous nasal resistance and the amount of reduction after
treatment.37
In the work of Hartgerink et al they found two subgroups, patients who
experienced either few or significant changes in resistance. Patients displaying
more significant changes tended to have shown high resistance pre-treatment.
This suggests that patients who could benefit from expansion for nasal
breathing are those who present impaired nasal breathing.
There are several causes for impaired nasal breathing including turbinate
hypertrophy, septal deviation, adenoid hypertrophy and nasal polyps, among
others. Using palatal expansion as a substitute for treating those medical
conditions does not seem to be the correct approach. In fact, Compadretti et al
found that the greater the skeletal diameters of the maxilla before treatment, the

9
less possible it is to increase nasal volume and reduce resistance through
expansion treatment. This reinforces the idea that maxillary expansion should
be performed only when it is necessary, meaning in cases of maxillary
constriction and not with the sole objective of improving nasal breathing.
However, when other reasons for impaired nasal breathing have been
discarded, maxillary constriction could be its cause, which could be treated. In
fact, it has been shown that persistent impaired nasal breathing after surgical
interventions is related to maxillary constriction.49 Haas concluded that
improved nasal breathing depended on the severity of the narrowing in the
nasal cavity before maxillary expansion.6 This was also found by Timms et al.24
They explained it applying Poiseuille's Law, which states that “in small ducts,
the flow varies with the fourth power of the radius”, in other words, double the
radius and the flow increases sixteen times.
According to these findings we believe that an interdisciplinary
orthodontist-otorhinolaryngologic approach seems to be the most rational option
in order to improve nasal breathing.

Method to expand

Doubts remain, however, about the best method to perform maxillary

expansion. Only one study compared different methods, therefore conclusions
cannot be drawn. Bazargani et al undertook a clinical trial comparing Tooth-
borne (TB) and Tooth-bone-borne (TBB) and found better results with TBB
appliances.33
Methods which better address the intermaxillary suture are those which
will probably have better outcomes. However, future research comparing
different methods is needed to obtain conclusions.

Limitations

As with any systematic review, we may have missed studies in the

literature despite our best efforts. Furthermore, the conclusions reached with a
systematic review and meta-analysis depend on the quality of the included
studies. The quality of the studies included in our case was too poor to be able
to answer our research question.

Conclusions
According to the available evidence, palatal expansion in pediatric
patients seems to decrease nasal resistance and increases nasal flow. However,
the quality of the available evidence does not allow physicians to use palatal
expansion to merely improve nasal breathing. We suggest that palatal
expansion might be an adjuvant treatment worthy of consideration in impaired
nose breathing when maxillary constriction, independent of crossbite, is the
cause. It implies treating all other implied causes (adenoids hypertrophy,
turbinate hypertrophy, septal deviation). However, further evidence is needed
to make this formal recommendation.
10
 We encourage researchers to develop good quality studies using
adequate inclusion criteria, controlling confounding factors and to always
perform analyses with decongestants.

11
 Bibliography
1. Bresolin D, Shapiro GG, Shapiro PA, et al. Facial characteristics of
children who breathe through the mouth. Pediatrics. 1984;73(5):622-625.
2. Lione R, Franchi L, Huanca Ghislanzoni LT, Primozic J,
Buongiorno M, Cozza P. Palatal surface and volume in mouth-breathing
subjects evaluated with three-dimensional analysis of digital dental casts-a
controlled study. Eur J Orthod. 2015;37(1):101-104. doi:10.1093/ejo/cju018
3. Laptook T. Conductive hearing loss and rapid maxillary
expansion. Report of a case. Am J Orthod. 1981;80(3):325-331. doi:10.1016/0002-
9416(81)90294-3
4. Thilander B, Pena L, Infante C, Parada SS, de Mayorga C.
Prevalence of malocclusion and orthodontic treatment need in children and
adolescents in Bogota, Colombia. An epidemiological study related to different
stages of dental development. Eur J Orthod. 2001;23(2):153-167.
doi:10.1093/ejo/23.2.153
5. Buck LM, Dalci O, Darendeliler MA, Papageorgiou SN,
Papadopoulou AK. Volumetric upper airway changes after rapid maxillary
expansion: a systematic review and meta-analysis. Eur J Orthod. 2017;39(5):463-
473. doi:10.1093/ejo/cjw048
6. Haas A. Rapid expansion of the maxillary dental arch and nasal
cavity by opening the mid palatal suture. Angle Orthod. 1961;31:73–90.
7. Occasi F, Duse M, Vittori T, et al. Primary school children often
underestimate their nasal obstruction. Rhinology. 2016;54(2):164-169.
doi:10.4193/Rhin15.120
8. Shea BJ, Reeves BC, Wells G, et al. AMSTAR 2: a critical appraisal
tool for systematic reviews that include randomised or non-randomised studies
of healthcare interventions, or both. BMJ. 2017;358:j4008. doi:10.1136/bmj.j4008
9. O’Sullivan D, Wilk S, Michalowski W, Farion K. Using PICO to
align medical evidence with MDs decision making models. Stud Health Technol
Inform. 2013;192:1057.
10. National Institute for Health and Care Excellence. Methods for the
Development of NICE Public Health Guidance. National Institute for Health and
Care Excellence (NICE); 2012.
11. Lagravere MO, Major PW, Flores-Mir C. Long-term skeletal
changes with rapid maxillary expansion: a systematic review. Angle Orthod.
2005;75(6):1046-1052. doi:10.1043/0003-3219(2005)75[1046:LSCWRM]2.0.CO;2
12. Itikawa CE, Valera FCP, Matsumoto MAN, Lima WTA. Effect of
rapid maxillary expansion on the dimension of the nasal cavity and on facial
morphology assessed by acoustic rhinometry and rhinomanometry. Dent Press J
Orthod. 2012;17(4):129-133. doi:10.1590/S2176-94512012000400024
13. Ottaviano G, Frasson G, Favero V, et al. N-butanol olfactory
threshold and nasal patency before and after palatal expansion in children. A
preliminary study. Int J Pediatr Otorhinolaryngol. 2014;78(10):1618-1623.
doi:10.1016/j.ijporl.2014.07.006
14. Di Vece L, Doldo T, Faleri G, et al. Rhinofibroscopic and

12
Rhinomanometric Evaluation of Patients with Maxillary Contraction Treated
with Rapid Maxillary Expansion. A Prospective Pilot Study. J Clin Pediatr Dent.
2018;42(1):27-31. doi:10.17796/1053-4628-42.1.5
15. Warren DW, Hershey HG, Turvey TA, Hinton VA, Hairfield WM.
The nasal airway following maxillary expansion. Am J Orthod Dentofac Orthop
Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. 1987;91(2):111-116.
doi:10.1016/0889-5406(87)90467-7
16. Basciftci FA, Mutlu N, Karaman AI, Malkoc S, Küçükkolbasi H.
Does the timing and method of rapid maxillary expansion have an effect on the
changes in nasal dimensions? Angle Orthod. 2002;72(2):118-123.
doi:10.1043/0003-3219(2002)072<0118:DTTAMO>2.0.CO;2
17. Oliveira De Felippe NL, Da Silveira AC, Viana G, Kusnoto B,
Smith B, Evans CA. Relationship between rapid maxillary expansion and nasal
cavity size and airway resistance: short- and long-term effects. Am J Orthod
Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod.
2008;134(3):370-382. doi:10.1016/j.ajodo.2006.10.034
18. Picchi F, Fiorelli G, Bolognini E, Piccini A. [Otorhinological
evaluations of patients undergoing rapid disjunction of the median palatine
suture]. Minerva Stomatol. 1990;39(1):15-18.
19. Timms DJ. The reduction of nasal airway resistance by rapid
maxillary expansion and its effect on respiratory disease. J Laryngol Otol.
1984;98(4):357-362. doi:10.1017/s0022215100146730
20. Linder-Aronson S, Aschan G. Nasal resistance to breathing and
palatal height before and after expansion of the median palatine suture. Odontol
Revy. 1963;14:254-270.
21. Doruk C, Sökücü O, Sezer H, Canbay EI. Evaluation of nasal
airway resistance during rapid maxillary expansion using acoustic rhinometry.
Eur J Orthod. 2004;26(4):397-401. doi:10.1093/ejo/26.4.397
22. Piccini A, Giorgetti R, Fiorelli G. [Nasal respiratory stenosis and
maxillary hypoplasia. Changes after orthodontic treatment with rapid palatal
expansion]. Acta Otorhinolaryngol Ital Organo Uff Della Soc Ital Otorinolaringol E
Chir Cerv-facc. 1989;9(4):375-380.
23. Hartgerink DV, Vig PS, Abbott DW. The effect of rapid maxillary
expansion on nasal airway resistance. Am J Orthod Dentofac Orthop Off Publ Am
Assoc Orthod Its Const Soc Am Board Orthod. 1987;92(5):381-389.
doi:10.1016/0889-5406(87)90258-7
24. Timms DJ. The effect of rapid maxillary expansion on nasal
airway resistance. Br J Orthod. 1986;13(4):221-228. doi:10.1179/bjo.13.4.221
25. Chiari S, Romsdorfer P, Swoboda H, Bantleon H-P, Freudenthaler
J. Effects of rapid maxillary expansion on the airways and ears--a pilot study.
Eur J Orthod. 2009;31(2):135-141. doi:10.1093/ejo/cjn092
26. Cozza P, Di Girolamo S, Ballanti F, Panfilio F. Orthodontist-
otorhinolaryngologist: an interdisciplinary approach to solve otitis media. Eur J
Paediatr Dent. 2007;8(2):83-88.
27. Farronato G, Maspero C, Russo E, Periti G, Farronato D. Headache
and transverse maxillary discrepancy. J Clin Pediatr Dent. 2008;33(1):67-74.

13
doi:10.17796/jcpd.33.1.j82n127877250863
28. Giuca MR, Pasini M, Galli V, Casani AP, Marchetti E, Marzo G.
Correlations between transversal discrepancies of the upper maxilla and oral
breathing. Eur J Paediatr Dent. 2009;10(1):23-28.
29. De Stefano A, Baffa C, Cerrone D, et al. Management of recurrent
otitis media with rapid maxillary expansion: our experience. B-ENT.
2009;5(1):13-17.
30. Compadretti GC, Tasca I, Bonetti GA. Nasal airway measurements
in children treated by rapid maxillary expansion. Am J Rhinol. 2006;20(4):385-
393.
31. Langer MRE, Itikawa CE, Valera FCP, Matsumoto MAN,
Anselmo-Lima WT. Does rapid maxillary expansion increase nasopharyngeal
space and improve nasal airway resistance? Int J Pediatr Otorhinolaryngol.
2011;75(1):122-125. doi:10.1016/j.ijporl.2010.10.023
32. Wertz RA. Changes in nasal airflow incident to rapid maxillary
expansion. Angle Orthod. 1968;38(1):1-11. doi:10.1043/0003-
3219(1968)038<0001:CINAIT>2.0.CO;2
33. Bazargani F, Magnuson A, Ludwig B. Effects on nasal airflow and
resistance using two different RME appliances: a randomized controlled trial.
Eur J Orthod. 2018;40(3):281-284. doi:10.1093/ejo/cjx081
34. Matsumoto MAN, Itikawa CE, Valera FCP, Faria G, Anselmo-
Lima WT. Long-term effects of rapid maxillary expansion on nasal area and
nasal airway resistance. Am J Rhinol Allergy. 2010;24(2):161-165.
doi:10.2500/ajra.2010.24.3440
35. Monini S, Malagola C, Villa MP, et al. Rapid maxillary expansion
for the treatment of nasal obstruction in children younger than 12 years. Arch
Otolaryngol Head Neck Surg. 2009;135(1):22-27. doi:10.1001/archoto.2008.521
36. Halicioğlu K, Kiliç N, Yavuz İ, Aktan B. Effects of rapid maxillary
expansion with a memory palatal split screw on the morphology of the
maxillary dental arch and nasal airway resistance. Eur J Orthod. 2010;32(6):716-
720. doi:10.1093/ejo/cjp164
37. White BC, Woodside DG, Cole P. The effect of rapid maxillary
expansion on nasal airway resistance. J Otolaryngol. 1989;18(4):137-143.
38. OCEBM Levels of Evidence. CEBM. Published May 1, 2016.
Accessed November 10, 2019. https://www.cebm.net/2016/05/ocebm-levels-
of-evidence/
39. Ottaviano G, Maculan P, Borghetto G, et al. Nasal function before
and after rapid maxillary expansion in children: A randomized, prospective,
controlled study. Int J Pediatr Otorhinolaryngol. 2018;115:133-138.
doi:10.1016/j.ijporl.2018.09.029
40. Ramires T, Maia RA, Barone JR. Nasal cavity changes and the
respiratory standard after maxillary expansion. Braz J Otorhinolaryngol.
2008;74(5):763-769. doi:10.1016/S1808-8694(15)31388-4
41. Neeley WW, Edgin WA, Gonzales DA. A review of the effects of
expansion of the nasal base on nasal airflow and resistance. J Oral Maxillofac
Surg Off J Am Assoc Oral Maxillofac Surg. 2007;65(6):1174-1179.

14
doi:10.1016/j.joms.2006.06.295
42. Kiliç N, Oktay H. Effects of rapid maxillary expansion on nasal
breathing and some naso-respiratory and breathing problems in growing
children: a literature review. Int J Pediatr Otorhinolaryngol. 2008;72(11):1595-
1601. doi:10.1016/j.ijporl.2008.07.014
43. Castillo JL. Maxillary expansion may increase airway dimensions
and improve breathing. J Evid-Based Dent Pract. 2012;12(1):14-17.
doi:10.1016/j.jebdp.2011.12.007
44. Baratieri C, Alves M, de Souza MMG, de Souza Araújo MT, Maia
LC. Does rapid maxillary expansion have long-term effects on airway
dimensions and breathing? Am J Orthod Dentofac Orthop Off Publ Am Assoc
Orthod Its Const Soc Am Board Orthod. 2011;140(2):146-156.
doi:10.1016/j.ajodo.2011.02.019
45. Bucci R, Montanaro D, Rongo R, Valletta R, Michelotti A, D’Antò
V. Effects of maxillary expansion on the upper airways: Evidence from
systematic reviews and meta-analyses. J Oral Rehabil. 2019;46(4):377-387.
doi:10.1111/joor.12766
46. Zapletal A, Chalupová J. Nasal airflow and resistance measured
by active anterior rhinomanometry in healthy children and adolescents. Pediatr
Pulmonol. 2002;33(3):174-180. doi:10.1002/ppul.10066
47. Clement P a. R, Gordts F, Standardisation Committee on Objective
Assessment of the Nasal Airway, IRS, and ERS. Consensus report on acoustic
rhinometry and rhinomanometry. Rhinology. 2005;43(3):169-179.
48. Hershey HG, Stewart BL, Warren DW. Changes in nasal airway
resistance associated with rapid maxillary expansion. Am J Orthod.
1976;69(3):274-284. doi:10.1016/0002-9416(76)90076-2
49. Williams R, Patel V, Chen Y-F, et al. The Upper Airway Nasal
Complex: Structural Contribution to Persistent Nasal Obstruction. Otolaryngol--
Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2019;161(1):171-177.
doi:10.1177/0194599819838262

15
Legends for figures
Figure1: Flow chart
Figure 2: Nasal airway resistance difference (uncontrolled and controlled
studies).
Figure 3: Nasal airway resistance with nasal decongestant.
Figure 4: Nasal airflow difference before and after treatment.
Figure 5: Funnel plot

16
Item assessed Characteristic Weight
Sample Size >50 20

26-50 10
0-25 0
Follow-up time (months) >12 20

7-12 10
0-6 0
Control group Comparable control group 20
No comparable control group 10
No control group 0
Decongestant Yes 20
No 0
Control of confounding factors ENT evaluation with sample selection 30
ENT evaluation without sample selection 10
No 0
Lost to follow-up (%) 0-10% 10
>10% 0
Total
Table 1 Quality score. ENT (otolaryngologist)
Table 2 - Description of the included studies. NR (not reported).

Author Q Design / Sample Age (years). Initial diagnosis Technique Main outcome Decongestion Follow-up
(Year) Score Level of size and Mean (M), (indication) (difference, 95% (months)
evidence sex median (Md), confidence interval)
(range)
Bazargani F 40 Clinical trial. 16 (NR) M 9.7 ± 1.5 Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.05 (-0.19, Yes 0
(2018) Level 2b. crossbite) Tooth-borne s/cm3) 0.29)
expander.
Activation: 0.5 Airflow 5.2 (-33.06,
mm/day (cm3/s) 43.46)
Retention: NR.
Amount activated:
4.80 mm ± 1.39
14 (NR) M 10.2 ± 1.4 Appliance: RPE. Resistance (Pa 0.22 (0.00,
miniscrew implants. s/cm3) 0.44)
Activation: 0.5
mm/day Airflow 55,4 (-0.40,
Retention: NR. (cm3/s) 111.20)
Amount activated:
5.48 mm ± 0.98.
Ottaviano G 30 Clinical trial. Case: 11 Case: M 8.27 ± Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.02 (-0.03, No 6
(2018) Level 2b. (NR) 1.62 crossbite) Hyrax-type. s/cm3) 0.07)
Control: 11 Control: M 8.27 ± Activation: 0.2
(NR) 1.25 mm/day
Retention: NR.
Amount activated:
6.04 ± 1.07 mm
Di Vece L 20 Quasi- 30 (12 M, M 8.7 ± NR. Orthodontic indication. (posterior Appliance: RPE. Resistance (Pa 0.44 (0.21, No 6
(2018) experimental. 18 F) crossbite) Hyrax-type. s/cm3) 0.67)
Level 4. Activation: 0.5
mm/day/2 weeks,
then 0.25/day.
Retention: NR.
Amount activated:
5.59 ± 1.45 mm
Halicioğlu K 30 Quasi- 15 (7 M, 8 M 12.89 ± NR Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.02 (0.00, Yes 6
(2010) experimental. F) (11–15) crossbite) Memory palatal split s/cm3) 0.04)
Level 4. screw
 Activation: 1.5
mm/day.
Retention: 6 months.
Amount activated:
NR
Langer MR 40 Quasi- 25 (NR) M 8.2 ± NR (7- Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.02 (-0.05, No 30
(2010) experimental. 10) crossbite) and not treated nasal Haas disjunctor. s/cm3) 0.09)
Level 4. obstruction. Activation: 0.5
mm/day.
Retention: 3 months.
Amount activated:
NR
Matsumoto 40 Quasi- 27 (NR) NR ± NR (7-10) Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.07 (-0.05, No 30
MA (2010) experimental. crossbite) and not treated nasal Haas disjunctor. s/cm3) 0.20)
Level 4. obstruction. Activation: 0.5
mm/day.
Retention: 3 months.
Amount activated:
NR
De Stefano A 40 Quasi- 27 (12 F, 5 7 ± NR (6-8) Recurrent otitis media, adenoid Appliance: Hyrax- Resistance (Pa 0.71 (No No 12
(2009) experimental. M) hypertrophy, skeletal type. s/cm3) SA)
Level 4. development syndrome Activation: 0.5
mm/day.
Retention: 3 months.
Amount activated:
NR
Monini S 70 Quasi- Case: 66 Case cohort: M Orthodontic indication (maxillary Appliance: RPE. Resistance (Pa 0.50 (0.10, No 0 (28)
(2009) experimental. (NR). 7.85 ± NR (5-10) constriction) and not treated nasal Hyrax-type. s/cm3) 0.90) 12 (38)
Level 4. obstruction and snoring. Activation: 0.5
mm/day. Airflow 61.4 (12.0,
Retention: 12 (cm3/s) 110.8)
months.
Amount activated:
NR
Compadretti 110 Before-after Case: 27 (13 Case: M 9.5 ± NR ENT indication (nasal Appliance: RPE. Resistance (Pa 0.20 (-0.66, Yes Case: 12
GC (2006) clinical trial. M, 14 F) (5-13) obstruction, no other causes than Hyrax-type. s/cm3) 1.06) Control: 11
Level 1b. Control: 24 Control: M 10.2 ± maxillary constriction) and Activation: 0.5
(16 M, 18 NR (8-12) orthodontic indication (posterior mm/day.
F) crossbite)
Retention: 3 months.
Amount activated:
 NR

Enoki C 30 Quasi- 29 (NR) NR ± NR (7-10) Orthodontic indication (posterior Appliance: RPE. Resistance (Pa 0.11 (0.06, No 3
(2006) experimental. crossbite) Haas disjuntor s/cm3) 0.16)
Level 4. Activation: 0.5
mm/day.
Retention: NR
Amount activated:
NR
White BC 30 Quasi- 11 (M 4, F NR ± NR (8-14) Orthodontic indication Appliance: RPE. Resistance (Pa 0.12 (0.06, Yes 10
(1989) experimental. 7) Hyrax-type. s/cm3) 0.19)
Level 4. Activation: 0.5
mm/day.
Retention: NR
Amount activated:
NR
Hershey HG 20 Quasi- 17 (6 M, 11 NR ± NR (11-14) Orthodontic indication Appliance: RPE. Resistance (Pa 0.24 (0.11, No 3
(1976) experimental. F) acrylic disjuntor s/cm3) 0.36)
Level 4. (n=6), Hyrax-type
(n=11).
Activation: 0.5
mm/day.
Retention: 3 months
Amount activated:
NR
Wertz RA 20 Quasi- 4 (2 M, 2 F) 11.25 ± NR (10- Orthodontic indication Appliance: RPE. Airflow 9.96 (- No 0
(1968) experimental. 13) Rigid split palate (cm3/s) 58.69,
Level 4. device. 78.61)
9 (3 M, 6 F) NR ± NR (8-15) Activation: 0.45 29,92 (- Yes
mm/day. 7.89,
Retention: 3 months 67.73)
Amount activated:
NR