ORIGINAL ARTICLE

A comparative analysis of aerodynamic

and anatomic characteristics of upper
airway before and after mini-implant–
assisted rapid maxillary expansion
Hongyi Tang, Panpan Liu, Qiuping Xu, Yingyue Hou, and Jing Guo
Jinan, China

Introduction: The objective of this research was to observe changes in aerodynamics and anatomic character-
istics of the upper airway after mini-implants assisted rapid maxillary expansion and to evaluate the correlation
between the 2 changes of the upper airway in young adults. Methods: Thirty consecutive patients (mean age,
23.82 6 3.90 years; median, 24.5 years; 9 males, 21 females) were involved. Cone-beam computed tomography
was taken before activation and over 3 months. Three-dimensional models of the upper airway were
reconstructed on the basis of cone-beam computed tomography. The anatomic characteristics of the upper
airway, including volume, area, transverse, and sagittal diameter, were measured. The aerodynamic
characteristics of the upper airway were calculated on the basis of 3-dimensional models using computational
fluid dynamics. The correlation between the changes in aerodynamics and anatomic characteristics of the
upper airway was explored. Results: The enlargements of the volume of the total pharynx, nasopharynx, and
oropharynx were found (9.99%, 20.7%, and 8.84%, respectively). The minimum cross-sectional area
increased significantly (13.6%). The airway resistance (R) and maximum velocity (Vmax) decreased
significantly in both the inspiration and expiration phase (inspiration: R, 26.8%, Vmax, 15.7%; expiration: R,
24.7%, Vmax, 16.5%). The minimum wall shear stress reduced significantly only in the inspiration phase
( 26.3%). The correlations between decreased R and increased volume and minimum cross-sectional area
were observed. Conclusions: Mini-implants assisted rapid maxillary expansion is an effective device for
improving anatomic characteristics represented by the total volume of the upper airway and minimum cross-
sectional area, which contributed to the respiratory function depending on the favorable changes of
aerodynamic characteristics including resistance, velocity, and minimum wall shear stress. (Am J Orthod
Dentofacial Orthop 2021;159:e301-e310)

O
bstructive sleep apnea (OSA) is a breathing disor-
der during sleep characterized by recurrent apnea
and hypopnea, which is associated with narrow
upper airway, obesity, hypertension, and other adverse
From the Department of Orthodontics, School and Hospital of Stomatology,
Shandong University, Shandong Key Laboratory of Oral Tissue Regeneration,
and Shandong Engineering Laboratory for Dental Materials and Oral Tissue
Regeneration, Jinan, Shandong, China.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Jing Guo, Department of Orthodontics, School and
Hospital of Stomatology, Shandong University, Shandong Key Laboratory of Oral
Tissue Regeneration, and Shandong Engineering Laboratory for Dental Materials
and Oral Tissue Regeneration, Number 44-1, Wenhua W Rd, Jinan, Shandong
250012, China; e-mail, guojing@sdu.edu.cn.
Submitted, September 2020; revised, November 2020; accepted, December
2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.12.013
clinical diseases.1-3 In addition, some studies reported
craniofacial disharmonies such as midface hypoplasia
and narrow dentition were predisposing factors in the
occurrence and progress of OSA, according to the
influence of upper airway and muscular function.4,5
OSA was a multifactor disease, and orthodontic treatment
was only an effective method in treating OSA that was
mainly caused by structural stenosis of the upper airway
because of skeletal craniofacial disharmony. In contrast,
the effects of orthodontic treatment were limited for
OSA caused by other factors such as heredity, overweight,
and dyslipidemia.
Rapid maxillary expansion (RME) is a conventional
treatment method correcting transverse maxillary defi-
ciency.6 Some studies have reported the effects of RME
could increase the volume of the upper airway,7-9 and
Cistulli et al10 first suggested RME could be a therapy
for patients with OSA in 1998. However, conventional
e301
e302
tooth anchored RME had dental side effects, such as
buccal tipping of maxillary first molars11 and the reduc-
tion of buccal attachment of alveolar bone, and was not
suitable for nongrowing patients whose midpalatal su-
ture had been fused.12
To reduce the undesirable side effects, mini-implants
assisted rapid maxillary expansion (MARME) was de-
signed to provide skeletal expansion guaranteed by 4
mini-implants and minimize the dental side effects
compared with RME.13,14 Some studies have pointed
out MARME could cause the enlargement of the upper
airway15,16 and be considered as an effective treatment
to alleviate the symptoms of OSA in adults.17
Computational fluid dynamics (CFD) is an engineering
technique used to solve problems relating to fluid or
airflow by simulating the access that the fluid or airflow
is going through a specific tube.18 CFD has been widely
used to simulate the airflow of the upper airway on the
basis of 3-dimensional (3D) data from CBCT, which could
assess the respiratory function of patients.19-21 It could
provide quantitative parameters describing the flow
process of air in the upper airway by exhibiting the
contours of aerodynamics characteristics such as
pressure drop, velocity, and wall shear stress.
The effects of MARME on the upper airway of 1 pa-
tient using CFD analysis was reported.17,22 However, the
changes of 1 patient might not illustrate the reliability
and universality of the effects of MARME. In addition,
previous studies evaluated the changes of the upper
airway after MARME on the basis of CBCT in the stand-
ing position. Based on these studies, the changes in a
group of patients on the basis of CBCT in supine position
had not been analyzed. In the optional location of taking
CBCT, the supine position was the position that could
describe the relatively narrow state of the upper airway,
and the standing position was the position that could
describe the relatively unobstructed state of the upper
airway. Both positions were valuable positions for taking
CBCT. In our study, we have gathered a group of pa-
tients, including 30 subjects from which the CBCT data
were of subjects in the supine position.
This study aimed to assess the changes of anatomic
and aerodynamics characteristics of the group of pa-
tients on the upper airway and to evaluate the correla-
tion between aerodynamics characteristics calculated
by CFD and the anatomy of the upper airway.
MATERIAL AND METHODS
From 2019 to 2020, patients who were diagnosed with
transverse deficiency of maxillary and have undergone
MARME were consecutively enrolled in this retrospective
study. During the collection process, 2 patients were
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Tang et al
Fig 1. MARME.
excluded because of loose mini-implants, and 3 patients
were excluded because of the defection of CBCT data. Ul-
timately, 30 patients were involved in this study. (mean
age, 23.82 6 3.90 years; median, 24.5 years; 9 males,
21 females; range, 18-33 years). The study was approved
by the relative ethical commission, and the informed con-
sent was signed by each patient.
The inclusion criteria for this study were shown as
followed: (1) aged .18 years; (2) maxillomandibular
skeletal transverse discrepancy 3 mm or greater (Fig 1);
(3) no history of expansion treatment or orthognathic
surgery; and (4) no severe dentofacial anomalies such
as a cleft lip or palate.
Each patient was treated by maxillary skeletal expan-
sion type II (BioMaterials Korea, Seoul, Korea) developed
by Brunetto et al23 at the University of California Los An-
geles, which consisted of 2 stainless steel arms soldered
to the bands on the maxillary first molars. After the
bands were bonded to the maxillary first molars, 4
mini-implants (diameter, 1.5 mm; length, 11 mm;
Mplant Series, BioMaterials Korea) were placed along
with guided slots in the midpalatal region under local
infiltration anesthesia (Fig 1). The jackscrew was orien-
tated on the midpalatal region generally, which was acti-
vated one sixth of a turn (0.13 mm) each day. The
amount of expansion was set depending on the severity
of each patient, which ranged from 40-60 turns, and the
duration of expansion ranged from 40 to 60 days. The
retention after activation was 3 months, allowing bone
formation in the separated maxillary suture.
CBCT scans (5G; NewTom, Verona, Italy) were ob-
tained before activation (T0) and over 3 months (T1).
The CBCT device was set at 110 kVp; 7.33 mA; 0.3-
mm voxel size; scan time, 4.8 seconds; and field of
view of 18 cm 3 16 mm. To assure the reliability of
the measurements from the airway segmentation, we
checked the position of each patient when taking
CBCT. Each patient was scanned in the supine position
in which the Frankfort horizontal plane (FHP) was
perpendicular to the floor, keeping the teeth in centric
Tang et al
Fig 2. Volume of the upper airway according to the 3 segments.
occlusion, the tongue in the position at the end of swal-
lowing (against the palate), breathing smoothly, no
swallowing15 and the duration of the scan was about
15 seconds which was not difficult for our patients to
keep constant. We had tried our best to ensure the uni-
formity of the head position and posture of our patients
during CBCT before and after the treatment. The unifor-
mity assured the reliability of the measurements to the
greatest extent. The CBCT data were saved as Digital Im-
aging and Communications in Medicine format.
The Digital Imaging and Communications in Medi-
cine data were imported into Dolphin Imaging software
(version 11.8; Dolphin Imaging and Management Solu-
tions, Chatsworth, Calif). The images were reoriented
along the palatal suture, tangent to the nasal floor and
parallel to the FHP. The upper airway was divided into
3 segments: nasopharynx, oropharynx, and hypophar-
ynx, and all the descriptions and definitions of anatomic
parameters were shown in Figures 2 and 3 and Table I.
The CBCT data were imported into Mimics software
(version 19.0; Materialise, Leuven, Belgium). The upper
airway was highlighted by setting the threshold between
1024 and 360 Hounsfield Units. The anterior upper
boundary was the line passing through PNS and S, the
upper boundary was the roof of the nasopharynx, and
the lower boundary was the plane across the C4 point
(the most anterior inferior point of the fourth cervical
vertebra) parallel to the FHP. All 3D models were ex-
ported as stereolithography files (Fig 4).
All the models of the upper airway were loaded into
software (ICEM 16.0; ANSYS, Canonsburg, Pa) to
American Journal of Orthodontics and Dentofacial Orthopedics
e303
generate tetrahedral volume mesh. According to the
complexity of the model of the upper airway, a typical
grid consisted of approximately 2 million tetrahedral
cells (Fig 5).
After mesh generation, the 3D mesh was imported
into software (FLUENT 16.0; ANSYS) for airflow simula-
tion. The steady-state Reynolds Averaged Navier-Stokes
formulation together with the laminar model was used
to model aerodynamic characteristics of the upper
airway. Second-order discretization schemes were
used, and the coupling between velocity and pressure
was achieved using the SIMPLE algorithm.24 The density
and the viscosity of the air were set as 1.225 kg/m3 and
1.79 3 10 05 kg/m/s, respectively, which was acquies-
cent in the software. An inlet volume flow rate of
166 mL s 1 (10 l min 1) was set in the airflow simula-
tion, and the standard atmospheric pressure of 0 Pa
was set for the inlet.25 The air within the upper airway
was thought to be adiabatic.24 In the inspiration phase,
the inlet boundary was set at the line passing through
PNS and S, and the outlet boundary was set at the plane
across the C4 point parallel to the FHP. Conversely, the
expiration phase was simulated by setting an inlet at
the plane across the C4 point parallel to the FHP and
outlet at the line passing through PNS and S. The itera-
tion numbers were 400 steps.
Airway resistance (R) was calculated by the following
formula: R 5 DP/Q. The total pressure drop between the
inlet and outlet of the upper airway (DP) was computed
by Pmax Pmin, and Q was the volume flow rate, which
was a constant. All the parameters were measured again
April 2021  Vol 159  Issue 4
e304 Tang et al

Fig 3. Anatomic measurements: A, CSAmin; B, transverse diameter of CSAmin; C, sagittal diameter of

CSAmin; D, cross-sectional area of interface1; E, transverse diameter of interface1; F, sagittal diameter
of interface1; G, cross-sectional area of interface2; H, transverse diameter of interface2; I, sagittal
diameter of interface2.

by 1 researcher (H.T.) after 1 week, and the average value
was applied in this study.
Statistical analysis
All the data were measured repeatedly after 1 week by
1 operator (H.T.), and the intraclass correlation coeffi-
cient was 0.91-0.97, indicating repeat agreement
regarding all measurements.
Statistical analysis was performed with SPSS software
(version 21; SPSS Inc, Chicago, Ill). The normality of data
distribution and the homogeneities of variances were
checked by the Shapiro-Wilk test and the Levene test,
respectively. A paired t test was used for the comparison
of normally distributed data between T0 and T1 and the
Wilcoxon test for the comparison of nonnormally
distributed data. Pearson correlation test was used to
analyze the correlation of normally distributed data,
and Spearman correlation test was used to assess the
correlation of nonnormally distributed data. A P
value \0.05 was determined as a statistical significance.

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Tang et al e305

Table I. The descriptions and definitions of relative parameters

Parameters Descriptions and definitions
CSAmin The minimum cross-sectional area of the upper airway
Transverse diameter of CSAmin The transverse line on the greatest transverse dimension at CSAmin
Sagittal diameter of CSAmin The sagittal line on the greatest sagittal dimension at CSAmin
Total volume The anterior border is the line passing through PNS and S; the inferior border
is the line parallel to the FHP passing through C4 (the anterior and inferior
point of the fourth cervical vertebra), and the posterior border is the
pharyngeal posterior wall
Superior boundary The line passing through PNS and S
Nasopharyngeal volume The anterior border is the line passing through PNS and S, the inferior border
is the line parallel to the FHP passing through PNS, and the posterior
border is the pharyngeal posterior wall
Interface1 The line parallel to the FHP passing through PNS
Transverse diameter of interface1 The transverse line on the greatest transverse dimension at interface1
Sagittal diameter of interface1 The sagittal line on the greatest sagittal dimension at interface1
Oropharyngeal volume The superior border is the line parallel to the FHP passing through PNS, the
inferior border is the line parallel to the FHP passing through the top of the
epiglottis, and the posterior border is the pharyngeal posterior wall
Interface2 The line parallel to the FHP passing through the top of the epiglottis
Transverse diameter of interface2 The transverse line on the greatest transverse dimension at interface2
Sagittal diameter of interface2 The sagittal line on the greatest sagittal dimension at interface2
Hypopharyngeal volume The superior border is the line parallel to the FHP passing through the top of
the epiglottis, the inferior border is the line parallel to the FHP passing
through C4 (the anterior and inferior point of the fourth cervical vertebra),
and the posterior border is the pharyngeal posterior wall
Inferior boundary The line parallel to the FHP passing through C4 (the anterior and inferior
point of the fourth cervical vertebra)

RESULTS diameter and sagittal diameter of CSAmin were found.

We observed significant changes in both anatomic
and aerodynamics characteristics.
The changes of anatomic parameters of the upper
airway between T0 and T1 were shown in Table II. Sig-
nificant increases in total volume (VTot), minimum
cross-sectional area (CSAmin) along with the transverse
Fig 4. 3D reconstructed model.
The 3 segments of the upper airway, volume, cross-
sectional area, and transverse diameter of nasopharynx
displayed significant increases from T0 to T1
(P \0.01). In addition, the volume of the oropharynx
showed a significant increase (P 5 0.043), and other pa-
rameters of the 3 segments of the upper airway did not
reveal significant changes.
The contours of pressure, minimum wall shear stress,
and the streamline of velocity during both inspiration
and expiration phase were shown in Figures 6 and 7.
The aerodynamic characteristics within the upper airway
between T0 and T1 were shown in Table III. Airway resis-
tance and maximum velocity during both inspiration
and expiration phase (Rin, Rex, Vmaxin, Vmaxex) showed
significant decreases by the comparison between T0
and T1 (Rin, P \0.001; Rex, P 5 0.001; Vmaxin,
P \0.01; Vmaxex, P \0.01; rate of changes: 26.8%,
24.7%, 15.7%, 16.5%, respectively). In terms of
minimum wall shear stress, minimum wall shear stress
decreased only in the inspiration phase (P \0.05; the
rate of changes, 26.3%).
Reduction of Rin, Rex, Vmaxin, and Vmaxex showed a
negative correlation with enlargement of VTot and CSAmin.
Decreases of Vmaxin and Vmaxex displayed a negative
correlation with increases of transverse diameter and

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Fig 5. Generated mesh of the upper airway.

Table II. Anatomic characteristics of the upper airway before (T0) and after (T1) MARME
Parameters T0 T1 P value
Total volume 25,518.43 6 6756.68 28,068.69 6 7142.77 0.007*
CSAmin 164.36 6 68.43 186.71 6 72.3 0.03*
Transverse diameter of CSAmin 21.55 6 5.22 23.69 6 5.40 0.007*
Sagittal diameter of CSAmin 8.66 6 3.04 9.86 6 2.69 0.003*
Nasopharyngeal volume 6463.86 6 1459.17 7806.69 6 1806.87 \0.001*
Cross-sectional area of interface1 434.71 6 113.83 481.95 6 132.88 0.003*
Transverse diameter of interface1 27.29 6 3.50 28.52 6 3.90 0.002*
Sagittal diameter of interface1 19.73 6 4.13 20.23 6 3.73 0.166
Oropharyngeal volume 10,886.67 6 3382.94 11,849.28 6 4306.25 0.043*
Cross-sectional area of interface2 240.53 6 104.08 256.46 6 104.94 0.364
Transverse diameter of interface2 27.09 6 5.86 28.4 6 5.03 0.213
Transverse diameter of interface2 11.72 6 3.55 12.36 6 3.34 0.276
Hypopharyngeal volume 8542.31 6 3426.18 8307.14 6 3237.12 0.387

*P \0.05.

sagittal diameter of CSAmin (P \ 0.01). In addition, the
increased volume of the nasopharynx, volume of the
oropharynx, and transverse diameter of the nasopharynx
correlated negatively with the decreases of Rin and Rex
(P \0.01) (Table IV).
DISCUSSION
The retrospective study focused on the changes of
anatomic and aerodynamic characteristics of the upper
airway after MARME. In this study, 30 young adults
were involved consecutively, and the mean age was
23.82 6 3.90 years (range, 18-33 years). The interval be-
tween T0 and T1 ranged from 4.3 to 5.6 months, which
assured the radiation exposure would not influence the
patients. Because all of the subjects were young adults
whose growth was slow, the interval assured growth,
and the changes in body mass index were very slight,
and there was no need to set a control group without
treatment. After MARME, we observed favorable effects
in both aerodynamic and anatomic characteristics.
In our study, the total volume of the upper airway
increased significantly after MARME. In published
studies, there were different results concerning the
changes in total airway volume. Kim et al16 reported sig-
nificant increases in total airway volume after MARME.
Another study indicated that although the effects of
bone-borne RME were more obvious than tooth-borne
RME, both tooth-borne RME and bone-borne RME
could increase the total volume of the upper airway.26
However, Yi et al27 found no significant changes in the

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Tang et al e307

Fig 6. Aerodynamic characteristics during inspiration: A, pressure drop; B, velocity; C, wall shear
stress.

Fig 7. Aerodynamic characteristics during expiration: A, pressure drop; B, velocity; C, wall shear
stress.

total upper airway after the same treatment, and the
study explained the negative result might be due to
elongation of posterior teeth, which caused mandibular
clockwise rotation. Therefore, vertical control guaran-
teed by 4 mini-implants in the midpalatal region, which
could avoid mandibular clockwise rotation, might be an
important factor to assure the enlargement of the upper
airway. That might be 1 of the factors why the effects of
bone-borne RME on the upper airway were more
obvious than tooth-borne RME as well.
Significant increases of CSAmin in the upper airway
were observed after MARME. A systemic review relating
to OSA have pointed out CSAmin was the most relevant
factor in assessing the severity of obstruction of the

American Journal of Orthodontics and Dentofacial Orthopedics April 2021  Vol 159  Issue 4
e308
Table III. Aerodynamic characteristics of the upper
airway before (T0) and after (T1) MARME
Parameter T0 T1 value
Airway resistance during 0.97 6 0.48 0.71 6 0.46 \0.001*
inspiration (Pa/L/min)
Maximum velocity during 2.16 6 0.73 1.82 6 0.76
inspiration (ms 1)
Minimum wall shear stress 2.78 6 1.22 2.05 6 1.17
during inspiration (Pa)
Airway resistance during 0.73 6 0.37 0.55 6 0.35
expiration (Pa/L/min)
Maximum velocity during 2.18 6 0.87 1.82 6 0.76
expiration (ms 1)
Minimum wall shear stress 2.28 6 0.92 1.90 6 0.85
during expiration (Pa)
*P \0.05.
upper airway.28 Therefore, the changes of CSAmin in our
study indicated MARME might be an effective method to
mitigate the obstruction of the upper airway.
Dividing the upper airway into 3 segments, we found
the changes in the upper airway occurred in the naso-
pharynx and oropharynx. The increase in the volume of
the nasopharynx and oropharynx is probably due to
changes in craniofacial structure and the surrounding
soft tissues generated by MARME. Some previous studies
have pointed out the shape and position of soft tissue,
such as soft palate and tongue, were important factors
influencing the volume of the upper airway.15,29 In addi-
tion, we could also find that the increases in the upper
airway occurred mostly in the nasopharynx, less in the
oropharynx, and scarcely in the hypopharynx. This
finding is probably due to MARME acting directly on
the nasomaxillary complex, closing to the nasopharynx.
In addition, the changes of oropharynx and hypopharynx
were limited by the surrounding hard and soft tissues.
Many studies stated clearly that CFD analysis was a
convenient, effective, and reliable engineering tool for
simulating the airflow of the upper airway, which could
evaluate the respiratory function of patients more pre-
cisely compared with anatomy.19-21,30,31 In our study,
Table IV. Correlation between changes of aerodynamic and anatomic characteristics
Parameter Total volume
Airway resistance during inspiration (Pa/L/min)
Maximum velocity during inspiration (ms 1)
Minimum wall shear stress during inspiration (Pa)
Airway resistance during expiration (Pa/L/min)
Maximum velocity during expiration (ms 1)
*P \0.05.
April 2021  Vol 159  Issue 4
Tang et al
we simulated the airflow of the upper airway of our pa-
tients on the basis of CBCT data in the supine position us-
ing CFD analysis. What needed to be mentioned was that
P the whole respiratory cycle was a very complex physio-
logical process. Although CFD was a novel method for
the simulation of the airflow of the upper airway, it could
0.003*
not simulate the airflow state of the upper airway
completely because of the effects of physiological regu-
0.01* lation of respiration during the breathing phase.
Airway resistance was calculated by the formulation
0.001* based on CFD calculations, and published studies have
0.002*
indicated maximum velocity could reveal the most
obstructive degree of the upper airway, which were
0.053 both reliable parameters evaluating the respiratory func-
tion of patients.32 In this study, airway resistance and
maximum velocity reduced significantly in both inspira-
tion phase and expiration phase, in agreement with
some previous studies (Rin, from 0.97 to 0.71 Pa/L/
min; Rex, from 0.73 to 0.55 Pa/L/min; Vin, from 2.16
to 1.82 m/s 1; and Vex, from 2.18 to 1.82 m/s 1). Hur
et al17 evaluated the effects of MARME on the upper
airway of 1 adult patient diagnosed with OSA using
CFD analysis and reported MARME was an effective
method for adult patients with moderate OSA. Zhao
et al22 reported a significant reduction of airway resis-
tance and velocity of 1 adult patient with transverse
maxillary deficiency after MARME.
Previous studies reported the aerodynamics charac-
teristics of the upper airway on the basis of CBCT in
standing position. In our study, we observed significant
changes in aerodynamics characteristics of the upper
airway based on CBCT in the supine position, which
was another important position of taking CBCT. In addi-
tion, the reliability and universality of the results were
better demonstrated by a group of 30 patients compared
with previous studies.
In addition, minimum wall shear stress decreased
significantly in the inspiration phase. Previous studies
pointed out immoderate minimum wall shear stress
derived from the high speed of airflow might have a
disadvantageous impact on the function of epithelial
cells in the upper airway.33 Thus, in this study, the
CSAmin Nasopharyngeal volume Oropharyngeal volume
0.549* 0.583* 0.510* 0.498*
0.767* 0.814* 0.309 0.499*
0.373 0.324 0.469* 0.263
0.638* 0.662* 0.525* 0.510
0.751* 0.818* 0.350 0.535
American Journal of Orthodontics and Dentofacial Orthopedics
Tang et al
reduction of minimum wall shear stress after MARME
indicated MARME had a positive effect on the function
of epithelial cells of the upper airway.
In our study, after MARME, significant negative cor-
relations were found between aerodynamic characteris-
tics represented by the decreases of Rin, Rex, and
anatomic characteristics represented by the increases
of VTot and CSAmin. Few studies have reported the corre-
lation between aerodynamic and anatomic characteris-
tics of the upper airway after MARME, whereas it had
been reported in other studies on different subjects.
Shah et al19 observed a significant correlation between
the reduction of volume of the upper airway and the in-
crease of mean pressure after mandibular setback sur-
gery. Chen et al20 found a significant correlation
between Rex and CSAmin in patients with OSA, and a
study of Twin-block reported a significant negative cor-
relation between pressure drop and volume of the upper
airway.32 The results we found were similar to previous
studies relating to different subjects, indicating the
changes in anatomic characteristics were related to the
changes in airway resistance after MARME.
Previous studies pointed out it was a duty for ortho-
dontists to understand the physiology of the upper
airway when using devices of maxillary expansion
because the nasomaxillary complex affected by maxillary
expansion provided anterior bony support for the upper
airway.8,9,34 By comparison between T0 and T1 of the 30
patients, we observed favorable changes of the upper
airway in the supine position during the inspiration
and expiration phase. Therefore, it could be hypothe-
sized that MARME was advantageous to improve the
respirable function of patients during the inspiration
and expiration phase. In addition, what needed to be
mentioned was that MARME might have some effects
on the treatment of OSA. In principle, it was only an
effective method in treating OSA, mainly caused by
structural stenosis of the upper airway because of skel-
etal craniofacial disharmony.
CONCLUSIONS
MARME is an effective device for improving anatomic
characteristics represented by the total volume of the up-
per airway and minimum cross-sectional area, which
contributed to the respiratory function depending on
the favorable changes of aerodynamic characteristics,
including resistance, velocity, and minimum wall shear
stress.
ACKNOWLEDGMENTS
The work was supported by R & D program of Shan-
dong Province [2018GSF118240] and the youth
American Journal of Orthodontics and Dentofacial Orthopedics
e309
scientific research of school of stomatology, Shandong
University [2019QNJJ02].
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