ORIGINAL ARTICLE

Cone-beam computed tomography evaluation

of dentoskeletal changes after asymmetric rapid
maxillary expansion
Zeliha Muge Baka, Mehmet Akin, Faruk Izzet Ucar, and Zehra Ileri
Konya, Turkey

Introduction: The aims of this study were to quantitatively evaluate the changes in arch widths and buccolingual
inclinations of the posterior teeth after asymmetric rapid maxillary expansion (ARME) and to compare the mea-
surements between the crossbite and the noncrossbite sides with cone-beam computed tomography (CBCT).
Methods: From our clinic archives, we selected the CBCT records of 30 patients with unilateral skeletal cross-
bite (13 boys, 14.2 6 1.3 years old; 17 girls, 13.8 6 1.3 years old) who underwent ARME treatment. A modified
acrylic bonded rapid maxillary expansion appliance including an occlusal locking mechanism was used in all pa-
tients. CBCT records had been taken before ARME treatment and after a 3-month retention period. Fourteen
angular and 80 linear measurements were taken for the maxilla and the mandible. Frontally clipped CBCT
images were used for the evaluation. Paired sample and independent sample t tests were used for statistical
comparisons. Results: Comparisons of the before-treatment and after-retention measurements showed that
the arch widths and buccolingual inclinations of the posterior teeth increased significantly on the crossbite
side of the maxilla and on the noncrossbite side of the mandible (P \0.05). Comparison of the 2 sides
showed statistically significant differences in both the maxilla and the mandible (P \0.05). Conclusions: After
ARME treatment, the crossbite side of the maxilla and the noncrossbite side of the mandible were more affected
than were the opposite sides. (Am J Orthod Dentofacial Orthop 2015;147:61-71)

P
osterior crossbite, a common malocclusion in pa-
tients seeking orthodontic treatment, can be
either a unilateral or a bilateral malocclusion of
the deciduous, mixed, or permanent dentition.1 The
incidence of posterior crossbite ranges from 7% to
23%, with unilateral crossbite being predominant.2-6
Unilateral posterior crossbite includes the teeth on 1
side of the arch and can be defined as either a
functional posterior crossbite or a true unilateral
posterior crossbite. In a functional posterior crossbite,
mild bilateral constriction of the maxillary arch that
creates occlusal interferences leads to a functional shift
of the mandible toward the crossbite side upon
closure. In a true unilateral posterior crossbite from
intra-arch or jaw asymmetry, a crossbite is seen in
Assistant professor, Department of Orthodontics, Faculty of Dentistry, Selcuk
University, Konya, Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
€
Address correspondence to: Zeliha Muge Baka, Selçuk Universitesi, Dişhekimli
gi
Fak€ultesi, Ortodonti AD, Selçuklu-42079, Kamp€ us/Konya, Turkey; e-mail,
mugen97@hotmail.com.
Submitted, March 2014; revised and accepted, September 2014.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.09.014
both centric relation and centric occlusion without a
functional shift of the mandible.7
Posterior crossbite is frequently caused by a trans-
verse maxillary skeletal deficiency that may have an
underlying congenital, developmental, traumatic, or iat-
rogenic cause.8 Therefore, posterior crossbite treatment
often aims to achieve maxillary expansion. However,
expansion modalities in posterior crossbite treatment
differ depending on whether the unilateral posterior
crossbite is functional or true and considering the diag-
nostic findings.1 Treating a functional posterior cross-
bite usually involves symmetric expansion of the
maxillary arch and elimination of the mandibular func-
tional shift.9 In a true unilateral posterior crossbite,
asymmetric expansion should expand the constricted
side of the maxillary arch and avoid overexpanding the
unaffected side.7 Thus far, several asymmetric maxillary
expansion devices have been used for correcting true
unilateral posterior crossbites, the effects of which
were assessed using dental models and lateral and post-
eroanterior cephalograms.1,10,11
For decades, orthodontists have largely been
bounded by 2-dimensional analyses for researching the
effects of maxillary expansion; the advent of cone-
beam computed tomography (CBCT) has added the third
61
62
dimension. CBCT for the maxillofacial region enables
multiplanar imaging and provides 3-dimensional (3D)
information, allowing for measurement of axial inclina-
tions of the dentition and changes in the transverse di-
mensions free from distortion, magnification, and
superimposition. CBCT imaging provides submillimeter
resolution images (isotropic resolution, 0.4-0.125 mm)
with relatively short scanning times (10-70 seconds)
and a reduced radiation dose (equivalent to that needed
for 4-15 panoramic radiographs).12
The effects of rapid maxillary expansion (RME) on the
dentoskeletal complex have been studied using dental
casts, lateral and posteroanterior cephalograms, and
CBCT.13-15 To the best of our knowledge, no studies
conducted thus far have evaluated the effects of
asymmetric rapid maxillary expansion (ARME) on the
dentoskeletal complex with CBCT. Therefore, the aims
of this study were to quantitatively evaluate the
changes in arch widths and buccolingual inclinations
of posterior teeth after ARME treatment and to
compare the measurements between the crossbite and
noncrossbite sides using CBCT. The null hypothesis was
that there are no statistically significant differences in
arch widths and buccolingual inclinations of the
posterior teeth between the crossbite and noncrossbite
sides after treatment with ARME.
MATERIAL AND METHODS
Sample size estimation was based on the standard de-
viations of a similar study by Kartalian et al,14 who found
a statistically significant increase of 5.42 6 3.02 mm in
external molar widths. Assuming an increase of 25% in
this previous finding, with an a error of 0.05 and a power
of 80%, we calculated that our sample size should be
30 patients per group.
The CBCT records of 30 patients with unilateral
skeletal crossbite (13 boys: mean age, 14.2 6 1.3 years;
range, 12.5-16 years; and 17 girls: mean age,
13.8 6 1.3 years; range, 12.3-15.4 years) who underwent
treatment with ARME were selected from the archives of
the Department of Orthodontics of Selcuk University,
Konya, Turkey. Ninety-six patients with unilateral poste-
rior crossbites were admitted to our orthodontic depart-
ment from 2010 to 2013, and 39 of them had unilateral
skeletal crossbites. Thirty patients who met the inclusion
criteria were selected for this study. All patients were in
the permanent dentition and had unilateral posterior
crossbites of the nonfunctional type with coincident
midlines. In 14 patients, the crossbite was on the left
side; in 16, it was on the right side. Any relationship of
the unilateral posterior crossbite and the mandibular
shift was evaluated clinically. The patients had no
January 2015
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Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Baka et al
Fig 1. ARME appliance.
craniofacial abnormalities or previous surgical or extrac-
tion treatment. The same orthodontist (Z.I.) treated all
patients. Ethical approval for this study was obtained
from the regional ethical committee on research of Sel-
cuk University.
The ARME appliance used was built by adding an
occlusal locking mechanism to a modified acrylic
bonded RME appliance. The modified acrylic bonded
RME appliance was a splint-type tooth and tissue-
borne appliance (Fig 1). The acrylic part of the appliance
extended over the occlusal and middle thirds of the
vestibular surfaces of all teeth. A hyrax screw (Dentau-
rum, Pforzheim, Germany) was placed in the acrylic plate
parallel to the second premolars and as near to the palate
as possible.13 Holes were drilled on the cusps of the
maxillary teeth on the ARME appliance to allow escape
of the luting cement. On the noncrossbite side, an acrylic
extension was formed that extended vertically from the
palatal part of the maxillary posterior teeth to the lingual
part of the mandibular posterior teeth. The acrylic part of
the appliance extended to the middle third of the vestib-
ular surfaces of the mandibular posterior teeth after
forming the occlusal tracks of these teeth. The occlusal
locking mechanism was formed by covering the lingual
and vestibular aspects of the mandibular posterior teeth
with acrylic.
The appliance was activated with a quarter turn twice
per day in the first week to overcome the resistance of
the sutures and once per day after the sutures were
mobilized. Expansion was stopped when the holes on
the palatal cusps of the maxillary posterior teeth
occluded with the buccal cusps of the mandibular poste-
rior teeth (average time, 4-6 weeks). The expander was
used for retention for the first 3 months and then
replaced with a transpalatal arch.
All CBCT images were obtained with a Kodak unit
(model CS 9300; Carestream Health, Rochester, NY) set
as follows: exposures were made at 8.0 mA and 70 kV
for 6.15 seconds with an axial slice thickness of
Baka et al 63

Fig 2. Maxillary linear and angular measurements on the crossbite and noncrossbite sides of the
maxilla: A, nasal and palatal floor measurements, and external maxillary widths measured relative to
the midsagittal plane at 4 levels: the buccal apex, buccal alveolar crest, most prominent point of the
crown, and buccal cusp tip; B, internal maxillary widths measured relative to the midsagittal plane at
2 levels: the palatal apex and palatal alveolar crest; C, the angle between the long axis of the palatal
root and a horizontal reference line parallel to the palatal plane.

0.18 mm. The patients were asked to put their heads in
the Frankfort horizontal position for the CBCT scans.
The DICOM images were imported, and cross-sectional
slices were obtained using Mimics software (version
14.01; Materialise, Leuven, Belgium). To establish the
standard orientation of the craniofacial structures,
3-dimensional reference planes were set. The Frankfort
horizontal plane was defined as the plane that passed
through bilateral porion and right orbitale. The midsag-
ittal plane was defined as the plane perpendicular to the
horizontal plane passing through nasion and the midpo-
rion point. The frontal plane was constructed from
nasion and perpendicular to the horizontal and midsag-
ittal planes. Each 3-dimensional rendered image was
then reoriented using the Frankfort horizontal, midsag-
ittal, and horizontal planes. All transverse linear and
angular measurements were recorded for each scan
before ARME treatment (T1) and after a 3-month
retention period (T2). One investigator (M.A.) took all
measurements.
In this study, 40 linear and 6 angular measurements
of the maxilla were taken (Fig 2). Kartalian et al14
described the linear and angular measurements for the
maxilla and the maxillary teeth. The nasal floor was as-
sessed relative to the midsagittal plane, parallel to the
lower border of the hard palate and tangent to the nasal
floor at its most superior level. The palatal floor was also
assessed relative to the midsagittal plane, parallel to the
lower border of the hard palate and tangent to the hard
palate. The external maxillary linear measurements were
taken relative to the midsagittal plane at the buccal alve-
olar crest, the most prominent point of the crown at the
buccal aspect, the buccal cusp tip, the apex of the buccal
root levels of the maxillary first and second premolars,
and the maxillary first molars on the crossbite and
noncrossbite sides. The internal maxillary linear mea-
surements were taken relative to the midsagittal plane
at the apex of the palatal root and the palatal alveolar
crest levels of each included tooth on the crossbite and
noncrossbite sides. The angular measurements of maxil-
lary teeth were taken relative to a horizontal reference
line parallel to the palatal plane. The angle between
the long axis of the maxillary teeth and the reference
line was measured for the crossbite and the noncrossbite
sides.
Forty linear and 8 angular measurements were taken
of the mandible (Fig 3). Baysal et al15 described the linear
and angular measurements for the mandible and the
mandibular teeth. The external mandibular linear mea-
surements were taken relative to the midsagittal plane
at the buccal alveolar crest, the most prominent point
of the crown at the buccal aspect, the buccal cusp tip
levels of the mandibular canines, the mandibular first
and second premolars, and the mandibular first molars
on the crossbite and noncrossbite sides. The internal
mandibular linear measurements were taken relative to
the midsagittal plane at the most prominent point of
the crown at the lingual aspect and the lingual alveolar
crest levels of each included tooth on the crossbite and
noncrossbite sides. The angular measurements of the
mandibular teeth were taken by considering a horizontal
reference line passing through the lower borders of the
mandible. The angle between the long axis of the
mandibular teeth and the reference line was measured
for the crossbite and noncrossbite sides.
Statistical analysis
The Statistical Package for the Social Sciences
(version 17.0; SPSS, Chicago, Ill) was used for data

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Fig 3. Mandibular linear and angular measurements on the crossbite and noncrossbite sides of the
mandible: A, external mandibular widths measured relative to the midsagittal plane at 3 levels: the
buccal alveolar crest, most prominent point of the crown, and buccal cusp tip; B, internal mandibular
widths measured relative to the midsagittal plane at 2 levels: the most prominent point of the crown
and the lingual alveolar crest; C, the angle between the long axis of the mesial root and a horizontal
reference line passing through the lower borders of the mandible.

analysis, and a P value of \0.05 was considered to be
statistically significant. Numeric data are given as means
and standard deviations. Twenty CBCT images were
randomly selected, and the same investigator (M.A.)
repeated the initial measurements of each side 30 days
after the first measurements. Intraclass correlation coef-
ficients were performed to assess the reliability of the
measurements, as described by Houston,16 in the same
images: the coefficients of reliability for the measure-
ments were greater than 0.918. In addition, a paired t
test was used to test the difference between the 2 trac-
ings; no significant difference was found (P .0.05), con-
firming the intraobserver reliability of the measurements.
The Shapiro-Wilk test for normality and the Levene
test for variance homogeneity were applied to the
data. The data at T1 and T2 were found to be normally
distributed, and homogeneity of variance was noted
among the groups. Therefore, the statistical evaluations
of these data were performed using parametric tests.
Statistically significant differences between the 2 sides
were determined with the independent t test. The paired
t test was used to determine the differences in mean
changes in each side.
RESULTS
The descriptive statistics and intragroup comparisons
of the crossbite and noncrossbite sides are shown in
Table I for the maxillary linear measurements. All maxil-
lary linear and angular measurements increased after
treatment with ARME. T1 to T2 comparisons showed
that these increases were statistically significant on the
crossbite side of the maxilla (P \0.05). Comparison of
changes in the maxillary linear measurements between
the 2 sides showed statistically significant differences
(Table II; P \0.05). The descriptive statistics and intra-
group comparisons of the crossbite and noncrossbite
sides are shown in Table III for the maxillary angular
measurements. Comparisons of the changes in maxillary
angular measurements between the 2 sides showed sta-
tistically significant differences (Table IV; P \0.001).
The descriptive statistics and an intragroup compar-
ison of the mandibular linear measurements for the
crossbite and noncrossbite sides are shown in Table I.
All mandibular linear measurements increased after
ARME treatment. T1 to T2 comparisons showed that
these increases were statistically significant predomi-
nantly on the noncrossbite side of the mandible
(P \0.05); however, the increases in buccal alveolar
crest measurements of the canines on the noncrossbite
side were not statistically significant (P .0.05). The in-
creases in alveolar crest measurements of the second
premolars and in all measurements of the first molars
on the crossbite side were statistically significant
(P \0.05). Comparison of changes in the mandibular
linear measurements between the sides showed statisti-
cally significant differences in almost all parameters, as
shown in Table II (P \0.05). The descriptive statistics
and an intragroup comparison of the mandibular
angular measurements for the crossbite and noncross-
bite sides are shown in Table III. All mandibular angular
measurements increased after ARME treatment. T1 to
T2 comparisons showed that these increases were
statistically significant except for the canines and first
premolars on the crossbite side of the mandible.
Comparison of changes in mandibular angular mea-
surements between the 2 sides showed statistically sig-
nificant differences, as shown in Table IV (P \0.05).
Thus, both the first and second parts of the null
hypothesis were rejected.

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Baka et al 65

Table I. Descriptive statistics and statistical comparisons of maxillary and mandibular linear measurements (mm)
before and after treatment with ARME
T1 T2

n Mean SD Mean SD Significance

Maxillary linear measurements
Nasal floor-Y
Crossbite side 30 31.24 1.78 33.17 1.69 *
Noncrossbite side 30 32.64 1.81 32.91 1.83 NS
Palatal floor-Y
y
Crossbite side 30 28.62 1.57 31.47 1.72
Noncrossbite side 30 30.28 1.75 30.89 2.04 NS
External
Apex
Crossbite side
y
First premolar-Y 30 14.76 0.93 18.25 1.19
Second premolar-Y 30 17.08 1.03 20.01 1.27 *
First molar-Y 30 18.27 1.41 20.62 1.52 *
Noncrossbite side
First premolar-Y 30 18.78 1.45 19.21 1.59 NS
Second premolar-Y 30 19.62 1.53 20.04 1.63 NS
First molar-Y 30 19.92 1.50 20.45 1.74 NS
Alveolar crest
Crossbite side
y
First premolar-Y 30 19.03 1.62 22.67 1.89
y
Second premolar-Y 30 21.32 2.01 24.28 1.93
First molar-Y 30 25.67 1.79 28.46 1.94 *
Noncrossbite side
First premolar-Y 30 21.37 1.68 22.05 1.54 NS
Second premolar-Y 30 22.79 1.83 23.19 2.08 NS
First molar-Y 30 27.19 1.80 27.88 2.17 NS
Buccal
Crossbite side
y
First premolar-Y 30 18.92 1.75 22.19 1.93
y
Second premolar-Y 30 21.27 2.09 24.38 2.31
First molar-Y 30 26.02 1.99 28.95 2.17 *
Noncrossbite side
First premolar-Y 30 21.49 2.14 22.26 2.10 NS
Second premolar-Y 30 22.57 2.13 23.21 2.06 NS
First molar-Y 30 27.03 1.88 27.92 2.08 NS
Occlusal
Crossbite side
y
First premolar-Y 30 16.14 1.45 19.72 1.67
y
Second premolar-Y 30 19.23 1.57 22.09 1.64
First molar-Y 30 23.87 2.07 26.02 2.13 *
Noncrossbite side
First premolar-Y 30 18.11 1.94 18.92 2.27 NS
Second premolar-Y 30 20.68 2.04 21.20 1.99 NS
First molar-Y 30 24.92 2.27 25.52 2.09 NS
Internal
Palatal apex
Crossbite side
y
First premolar-Y 30 11.23 0.73 14.86 0.89
y
Second premolar-Y 30 14.02 0.83 17.17 0.90
First molar-Y 30 14.62 0.92 17.21 0.88 *
Noncrossbite side
First premolar-Y 30 13.84 0.91 14.32 0.97 NS
Second premolar-Y 30 16.34 1.04 16.85 0.91 NS
First molar-Y 30 16.68 1.12 17.02 0.99 NS

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Table I. Continued

T1 T2

n Mean SD Mean SD Significance

Palatal alveolar crest
Crossbite side
y
First premolar-Y 30 12.04 0.81 14.97 1.03
y
Second premolar-Y 30 14.47 1.08 17.62 1.27
First molar-Y 30 15.79 1.17 18.08 1.31 *
Noncrossbite side
First premolar-Y 30 14.11 0.97 14.62 1.20 NS
Second premolar-Y 30 16.84 1.13 17.32 1.22 NS
First molar-Y 30 17.65 1.25 18.12 1.32 NS
Mandibular linear measurements
External
Occlusal
Crossbite side
Canine-Y 30 13.21 1.13 13.45 1.03 NS
First premolar-Y 30 18.84 1.25 18.97 1.17 NS
Second premolar-Y 30 20.54 1.35 20.82 1.21 NS
First molar-Y 30 26.91 1.31 28.03 1.33 *
Noncrossbite side
Canine-Y 30 12.10 1.12 13.72 1.28 *
First premolar-Y 30 16.92 1.19 18.74 1.31 *
y
Second premolar-Y 30 19.05 1.22 21.13 1.28
y
First molar-Y 30 25.82 1.53 28.02 1.37
Buccal
Crossbite side
Canine-Y 30 17.82 0.98 18.32 1.05 NS
First premolar-Y 30 19.82 1.13 20.35 1.20 NS
Second premolar-Y 30 24.22 1.42 25.06 1.33 NS
First molar-Y 30 28.23 1.72 29.41 1.63 *
Noncrossbite side
Canine-Y 30 16.37 1.05 18.05 1.17 *
First premolar-Y 30 19.04 1.23 21.02 1.27 *
Second premolar-Y 30 24.16 1.31 26.04 1.25 *
First molar-Y 30 27.89 1.52 29.75 1.64 *
Alveolar crest
Crossbite side
Canine-Y 30 16.42 1.41 17.03 1.36 NS
First premolar-Y 30 20.35 1.51 21.03 1.44 NS
Second premolar-Y 30 24.68 1.73 26.19 1.67 *
First molar-Y 30 28.13 1.49 29.78 1.66 *
Noncrossbite side
Canine-Y 30 16.68 1.26 17.62 1.34 NS
First premolar-Y 30 19.74 1.55 21.92 1.61 *
Second premolar-Y 30 25.72 1.73 27.45 1.88 *
y
First molar-Y 30 28.37 1.64 31.05 1.81
Internal
Lingual
Crossbite side
Canine-Y 30 12.04 0.92 12.42 1.07 NS
First premolar-Y 30 14.73 1.08 15.27 1.14 NS
Second premolar-Y 30 16.14 1.20 16.82 1.15 NS
First molar-Y 30 18.32 1.35 19.73 1.29 *
Noncrossbite side
Canine-Y 30 11.45 0.84 12.62 0.91 *
First premolar-Y 30 13.83 0.95 15.22 1.04 *
Second premolar-Y 30 15.56 1.14 17.24 1.22 *
y
First molar-Y 30 17.63 1.31 19.91 1.28

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Baka et al 67

Table I. Continued

T1 T2

n Mean SD Mean SD Significance

Alveolar crest
Crossbite side
Canine-Y 30 12.01 1.03 12.39 0.89 NS
First premolar-Y 30 15.12 1.11 15.53 0.93 NS
Second premolar-Y 30 17.34 1.26 18.63 1.47 *
First molar-Y 30 19.32 1.36 20.43 1.52 *
Noncrossbite side
Canine-Y 30 11.34 0.79 13.03 0.93 *
First premolar-Y 30 14.45 1.06 16.89 1.18 *
y
Second premolar-Y 30 16.67 1.19 19.34 1.37
y
First molar-Y 30 18.72 1.54 22.03 1.62

Y, Midsagittal plane; NS, not significant.

*P \0.05; yP \0.01.

DISCUSSION CBCT imaging enables a detailed evaluation of changes

True unilateral posterior crossbite is a less common
malocclusion than functional posterior crossbite.2,6
However, the appliances and biomechanics used in the
treatment of a true unilateral posterior crossbite are
important because the treatment requires appliances
that will exert a unilateral effect.1,10 There are few
studies concerning the characteristics and treatments
of patients with a true unilateral posterior crossbite.10
However, several treatment modalities have been recom-
mended, including a number of acrylic appliances such
as the removable Nord appliance, a bonded RME with
an occlusal index, and an RME with “reverse” crossbite
elastics on the normal occlusion side with a mandibular
lingual holding arch.1 In this study, an ARME appliance
created by adding an occlusal locking mechanism to the
modified acrylic bonded RME appliance was used to cor-
rect true unilateral posterior crossbites. This appliance
was designed to empower the anchorage of the teeth
on the noncrossbite side by including the mandibular
posterior teeth with the aid of the occlusal locking mech-
anism. The effects of RME on the dentoskeletal complex
have been studied with dental casts, lateral and poster-
oanterior cephalograms, and CBCT.13-15 To the best of
our knowledge, this is the first study to investigate the
effects of ARME on the dentoskeletal complex using
CBCT.
In a previous study, dental casts and posteroanterior
cephalograms were used to evaluate changes in the axial
inclinations of the dentition and the transverse dimen-
sions after asymmetric maxillary expansion.10 However,
in dental cast measurements, the roots of the teeth
may not be taken into account, and in posteroanterior
cephalometric measurements, superpositioning of the
teeth makes it hard to determine axial inclinations.
in the dentoskeletal complex. In this study, changes in
the maxillary and mandibular arch widths were deter-
mined at several levels, along with changes in the bucco-
lingual inclinations of the posterior teeth. Changes at
any level of the maxilla or mandible can be evaluated
easily and accurately using CBCT images.
The aims in treating true unilateral posterior crossbite
with an ARME appliance are to expand the crossbite side
of the maxillary arch and to create resistance for buccal
movement of the noncrossbite side. This is why we
decided to use the midsagittal plane as a reference plane
for comparing the treatment changes between the cross-
bite and noncrossbite sides. Furthermore, the midsag-
ittal plane is accepted as a reference plane in CBCT
studies for evaluating asymmetries.17,18
RME treatment increases the transverse dimension of
the maxillary arch by separating the maxillary halves;
however, this expansion is accompanied by bending of
the alveolar structures and buccal tipping of the poste-
rior maxillary teeth.19-21 Recently, the effects of RME
have been studied using CBCT.14,15 Kartalian et al14
evaluated measurements taken on CBCT scans to deter-
mine transverse dimension increases and the amount of
alveolar and dental tipping after RME treatment. They
reported significant increases in all measured transverse
dimensions and significant alveolar tipping. Baysal
et al15 evaluated changes in transversal arch dimensions
after RME, which they assessed using CBCT. They re-
ported that all maxillary and mandibular arch widths
increased and that the maxillary and mandibular poste-
rior teeth tipped buccally after RME. In this study, all
maxillary linear and angular measurements increased af-
ter ARME treatment, in accordance with the findings of
previous studies that assessed the effects of RME. These

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Table II. Comparison of changes in maxillary and mandibular linear measurements (mm) between the crossbite and
noncrossbite sides
Crossbite side Noncrossbite side

n Mean SD Mean SD Significance

Maxillary linear measurements
y
Nasal floor 30 1.93 0.93 0.27 0.29
z
Palatal floor 30 2.85 0.87 0.61 0.54
External
Apex
z
First premolar-Y 30 3.49 1.13 0.43 0.39
z
Second premolar-Y 30 2.93 0.89 0.42 0.32
y
First molar-Y 30 2.35 0.94 0.53 0.37
Alveolar crest
z
First premolar-Y 30 3.64 1.21 0.68 0.48
z
Second premolar-Y 30 2.96 1.17 0.40 0.43
z
First molar-Y 30 2.79 1.05 0.69 0.31
Buccal
z
First premolar-Y 30 3.27 1.24 0.77 0.53
z
Second premolar-Y 30 3.11 1.02 0.64 0.41
y
First molar-Y 30 2.93 0.93 0.89 0.56
Occlusal
z
First premolar-Y 30 3.58 0.87 0.81 0.43
y
Second premolar-Y 30 2.86 0.94 0.52 0.31
First molar-Y 30 2.15 0.79 0.60 0.48 *
Internal
Palatal apex
z
First premolar-Y 30 3.63 1.19 0.48 0.32
z
Second premolar-Y 30 3.15 1.08 0.51 0.46
z
First molar-Y 30 2.59 1.02 0.34 0.32
Palatal alveolar crest
z
First premolar-Y 30 2.93 0.93 0.51 0.37
z
Second premolar-Y 30 3.15 0.98 0.48 0.41
y
First molar-Y 30 2.29 0.84 0.47 0.29
Mandibular linear measurements
External
Occlusal
y
Canine-Y 30 0.24 0.54 1.62 0.62
y
First premolar-Y 30 0.13 0.48 1.82 0.73
y
Second premolar-Y 30 0.28 0.38 2.08 0.70
First molar-Y 30 1.12 0.92 2.20 0.73 *
Buccal
Canine-Y 30 0.50 0.39 1.68 0.53 *
y
First premolar-Y 30 0.53 0.42 1.98 0.78
Second premolar-Y 30 0.84 0.67 1.88 0.88 *
First molar-Y 30 1.18 1.02 1.86 0.94 *
Alveolar crest
Canine-Y 30 0.61 0.74 0.94 0.77 NS
y
First premolar-Y 30 0.68 0.59 2.18 0.69
Second premolar-Y 30 1.51 1.07 1.73 1.09 NS
First molar-Y 30 1.65 1.12 2.68 0.97 *
Internal
Lingual
Canine-Y 30 0.38 0.62 1.17 0.88 *
First premolar-Y 30 0.54 0.58 1.39 0.67 *
Second premolar-Y 30 0.68 0.61 1.68 0.78 *
First molar-Y 30 1.41 0.99 2.28 0.84 NS

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Baka et al 69

Table II. Continued

Crossbite side Noncrossbite side

n Mean SD Mean SD Significance

Alveolar crest
Canine-Y 30 0.38 0.62 1.69 0.82 *
y
First premolar-Y 30 0.41 0.32 2.44 0.59
Second premolar-Y 30 1.29 0.51 2.67 0.79 *
y
First molar-Y 30 1.11 0.78 3.31 0.96

Y, Midsagittal plane; NS, not significant.

*P \0.05; yP \0.01; zP \0.001.

Table III. Descriptive statistics and statistical compar- Table IV. Comparison of changes in maxillary and
isons of maxillary and mandibular angular measure- mandibular angular measurements ( ) between the
ments ( ) before and after ARME treatment crossbite and noncrossbite sides
T1 T2 Crossbite Noncrossbite
side side
n Mean SD Mean SD Significance
Maxillary angular measurements n Mean SD Mean SD Significance
Crossbite side Maxillary angular measurements
y z
First premolar 30 90.23 2.03 96.02 2.56 First premolar 30 5.79 2.04 1.07 0.74
y z
Second premolar 30 91.68 1.96 97.22 2.28 Second 30 5.54 1.86 0.79 0.62
y premolar
First molar 30 97.63 2.47 102.09 2.51
z
Noncrossbite side First molar 30 4.46 1.43 1.15 0.69
First premolar 30 94.35 2.15 95.42 2.28 NS Mandibular angular measurements
Second premolar 30 95.39 2.42 96.18 2.37 NS Canine 30 0.70 0.43 1.22 0.62 *
y
First molar 30 100.37 2.61 101.52 2.81 NS First premolar 30 0.52 0.38 2.46 0.73
Mandibular angular measurements Second 30 1.36 0.51 2.11 0.59 *
Crossbite side premolar
Canine 30 90.34 1.34 91.04 1.41 NS First molar 30 0.94 0.50 1.98 0.81 *
First premolar 30 88.21 1.52 88.73 1.61 NS
Second premolar 30 80.32 1.38 81.68 1.42 * *P \0.05; yP \0.01; zP \0.001.
First molar 30 76.27 1.23 77.21 1.07 *
Noncrossbite side
Canine 30 90.03 1.25 91.25 1.18 * in the literature. In this study, the amounts of buccal
First premolar 30 87.15 1.13 89.61 1.09 * crown tipping of the teeth on the crossbite and non-
Second premolar 30 80.07 1.32 82.18 1.52 * crossbite sides were approximately 5 and 1 , respec-
First molar 30 75.85 1.56 77.83 1.72 * tively. Our results are consistent with those of Toro glu
NS, Not significant. et al, who found that the molars on the crossbite side
*P \0.05; yP \0.01. (7.3 ) had greater buccal crown tipping than did those
on the noncrossbite side (2.5 ). The reason for the lower
increases were statistically significant on the crossbite tipping results in our study was the use of a more rigid
side of the maxilla. Comparison of changes between type of ARME appliance. As several authors have indi-
the sides showed that the maxillary first and second pre- cated, increasing the rigidity of an appliance reduces
molars and the maxillary first molars on the crossbite the rotational component of the forces along the long
side moved more buccally than did the opposing teeth. axis of the teeth.22,23 Also, differing from Toro glu
Negligible increases were measured for the buccal move- et al, we applied RME protocol in our study.
ments of the maxillary teeth and for the maxillary arch Haas19 stated that the mandibular arch expanded
widths on the noncrossbite side. Similar results were re- spontaneously, along with uprighting of the mandibular
ported by Toroglu et al,10 who evaluated the effect of an posterior teeth, in response to altered forces of occlusion
asymmetric maxillary expansion appliance on treating and changes in muscle balance after maxillary expansion.
true unilateral posterior crossbite. Although Toro glu In this study, all mandibular linear measurements
et al used a different appliance design and expansion increased after ARME treatment. These increases were
technique, the results of our study were compared with statistically significant, predominantly on the noncross-
their results because of the limited number of studies bite side of the mandible. The mandibular anchorage

American Journal of Orthodontics and Dentofacial Orthopedics January 2015
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70
unit consisted of the canine, the first and second premo-
lars, and the first molar connected via an acrylic occlusal
locking mechanism. Greater expansion on the noncross-
bite side could be related to the direct transmission of
expansion forces with the occlusal locking mechanism.
In this study, the maxillary molar on the noncrossbite
side (at the occlusal level) expanded by 0.6 mm, whereas
the mandibular molar on the same side expanded by
2.20 mm. Over the short term, the noncrossbite side
could be at risk of going edge to edge because the
mandibular molars on the noncrossbite side expanded
by 1.6 mm more than did the maxillary molars. In
contrast, Toro glu et al,10 who measured dental casts,
found that the mandibular posterior teeth on the cross-
bite side (0.6 mm) had greater expansion than did those
on the noncrossbite side (0.2 mm) after using an asym-
metric maxillary expansion appliance. The axial inclina-
tions of all mandibular posterior teeth increased after
ARME treatment in this study. Baysal et al15 evaluated
the changes in mandibular arch widths and buccolingual
inclinations of the mandibular posterior teeth after RME
using CBCT and found statistically significant increases
in long-axis measurements for all investigated teeth. Up-
righting of mandibular posterior teeth has been reported
after RME treatment in several studies, supporting our
results.15,19 In our study, we found that the mandibular
posterior teeth on the crossbite side showed less
uprighting than did those on the noncrossbite side. The
effects of RME on the dentoskeletal complex have been
studied extensively; however, to our knowledge, our
study is the first to use ARME to treat true unilateral
posterior crossbite. Therefore, the use of different
treatment regimens in other studies makes comparisons
with our study impossible.
The limitations of our study are as follows: (1) no
hand-wrist x-rays were taken for identification of the
developmental stages of growing patients, (2) the
required expansion was obtained by overcorrection of
the crossbite according to the clinician's judgment,
and (3) muscle splinting that might have masked a func-
tional mandibular shift was disregarded because the ef-
fect of muscle splinting is not detectable clinically.24
Further studies with different age ranges, sample sizes,
and appliances should be carried out.
This study addressed short-term changes after treat-
ment with ARME. Future studies should be done to
assess the long-term changes after ARME treatment
because of possible relapse over time.
CONCLUSIONS
Within the limitations of this study, we concluded that
the ARME appliance is effective for treating true
January 2015
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Baka et al
unilateral posterior crossbites. All maxillary and
mandibular arch widths increased, and the maxillary
and mandibular posterior teeth tipped buccally after
ARME treatment. This appliance provided anchorage
control on the noncrossbite side of the maxilla and al-
lowed for tooth expansion on the crossbite side of the
maxilla. In contrast, the noncrossbite side of the mandible
was more affected than the opposite side after ARME
treatment.
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