REVSTO-292; No of Pages 8

Original article
















Received: 
20 October 2015
Accepted:


Rapid maxillary expansion in adults: Can

10 June 2016 
 multislice computed tomography help choose




between orthopedic or surgical treatment?


 Expansion rapide des maxillaires chez l’adulte : le scanner


 peut-il aider à choisir entre traitement orthopédique et

 chirurgical ?



 A. Gueutiera,*, A. Paréa, A. Jolya, B. Laurea, G. de Pinieuxb, D. Gogaa
Available online at 

 a CHU Trousseau, University Francois-Rabelais, Department of Maxillo Facial and Facial Plastic
ScienceDirect 
 Surgery, Tours, France
b
www.sciencedirect.com CHU Trousseau, University Francois-Rabelais, Department of Pathology, Tours, France
Summary
Introduction. The aim of this study was to evaluate the accuracy of
Multislice Computed Tomography (MSCT) in the detection resis-
tance areas on the midpalatal suture (MPS) and thus to evaluate if
MSCT could be a help in the kind of maxillary expansion to be used
(pure orthodontic or surgically-aided) for the correction of transverse
maxillary deficiencies in adults.
Methods. Ten MSCT were obtained from 10 MPS removed from
fresh corpses (mean age: 79.4; extreme: 70–86). Three standardized
radiological regions of interest (ROI) were identified on each MPS
and were classified into ‘‘open’’ (group 1) or ‘‘closed’’ (group 2) by 3
independent radiologists. The 30 ROI were then histologically
analyzed according to 3 criteria: mean suture width (MSW), oblitera-
tion index (OI) and interdigitation index (Ii).
Results. Nine ROI were classified in group 1 (closed) and 21 in
group 2 (open). On the histological examination, the mean MSW was
396.9 mm in group 1 and 227.1 mm in group 2. OI was 3.098% and
9.309% and Ii was 1.25 and 1.34 respectively. Statistically signi-
ficant difference between the 2 groups was only found for the MSW.
We conclude that MSCT allows for the evaluation of the width of the
MPS, but not for the evaluation of the other possible parameters of
resistance we used. Therefore, it cannot predict precisely the amount
of résistance in the MPS and is not suited for the choice between pure
orthodontic or surgically-aided expansion.
ß 2016 Elsevier Masson SAS. All rights reserved.
* Corresponding author.
e-mail: gueutier.alexandre@hotmail.fr (A. Gueutier).
http://dx.doi.org/10.1016/j.revsto.2016.06.002 Rev Stomatol Chir Maxillofac Chir Orale 2016;xxx:1-8
2213-6533/ß 2016 Elsevier Masson SAS. All rights reserved.
Résumé
Introduction. Le but de cette étude était d’évaluer le degré de
précision dans la détection de zones de résistance au niveau de la
suture palatine médiane (SPM) du scanner multi-coupes et ainsi
d’être une aide dans le choix du type d’expansion maxillaire à utiliser
(orthodontique pure ou chirurgicalement assistée) pour la correction
de l’insuffisance transversale du maxillaire chez l’adulte.
Matériel et méthode. Dix scanners ont été réalisés sur des SPM
prélevées sur des pièces anatomiques (corps âgés de 79,4 ans en
moyenne ; extrêmes : 70–86). Trois régions d’intérêt radiologique
(RIR) standardisées ont été identifiées sur chaque suture de manière
standardisée et classées en « ouverte » (groupe 1) ou en « fermée »
(groupe 2) par 3 radiologues indépendants. Les 30 RIR ont ensuite
été analysées histologiquement en fonction de 3 critères : largeur
moyenne de la suture (LMS), index d’oblitération (IO) et index
d’interdigitation (II).
Résultats. Neuf RIR ont été classées dans le groupe 1 et 21 dans le
groupe 2. À l’examen histologique, la valeur moyenne de LMS était
de 396,9 mm dans le groupe 1 et de 227,1 mm dans le groupe 2. L’OI
était de 3,098 % et 9,309 % et l’IS était de 1,25 et 1,34 respecti-
vement. Une différence statistiquement significative a été retrouvée
uniquement pour LM. Nous en concluons que le scanner permet
d’évaluer la largeur de la suture intermaxillaire mais ne permet pas
d’évaluer les autres critères de résistance potentielle que nous avons
utilisés. Le scanner ne nous semble de ce fait pas être en mesure de
prédire l’importance de la résistance de la SPM et ne permet pas
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REVSTO-292; No of Pages 8
A. Gueutier et al.
Keywords: Maxillary expansion, Multidetector computed tomogra-
phy, Histology
Introduction
Transverse maxillary deficiency is a common form of dental
and skeletal dysmorphia. Several treatments are available for
the expansion of the midpalatal suture (MPS), whether these
are orthopedic, such as rapid maxillary expansion (RME),
surgical or orthodontico-surgical [1]. Surgical treatment is
suggested when the orthopedic treatment is risky because
of excessive resistance, or after failure of RME.
The histological study of the MPS showed histomorphometric
changes during growth. These changes are sources of resis-
tance [2,3]. During maturation, the MPS presents 3 main
changes: a reduction of its width, ossification and an increa-
singly sinuous path. This resistance is responsible for the
failure of orthopedic treatment or the onset of pain and
periodontal disease [4].
How patient and when does it propose surgical treatment to
prevent failure of RME? There is no consensus regarding to
chronological age [4]. Regarding the physiological age, wrist
radiographs are typically used to assess the end of bone
growth. However, the MPS continues to change once bones
have stopped growing. Its ossification is unpredictable until
the age of 30 years [3,5]. Radiology that allows the diagnosis
should be focused on the MPS. The occlusal radiography
enables it, but the superimposition of bony structures is
responsible for 50% false positive results [6].
Multislice computed tomography (MSCT) allows 3D vision and
excellent resolution of bone and soft tissue. Is MSCT able to
help us in our therapeutic choice for the correction of the
transverse maxillary?
The purpose of this study was to find out if MSCT of the
midpalatal suture could inform us of visible histological
parameters of resistance to select an appropriate treatment
for transverse maxillary deficiency.
Material and method
Material
Ten maxillay bones were from fresh corpses. The subjects
were between 70 and 86 year-old, with an average age of
79.4 years.
MSCT
A 64-slice scanner (Brillance 64, Philips Medical SystemW,
Eindhoven, the Netherlands) was used. The acquisitions of
2
Rev Stomatol Chir Maxillofac Chir Orale 2016;xxx:1-8
d’orienter le choix vers une distraction orthodontique pure ou
chirurgicalement assistée.
ß 2016 Elsevier Masson SAS. Tous droits réservés.
Mots clés : Expansion maxillaire, Scanner, Histologie
the MPS were obtained from a standard protocol for a facial
skeleton. The parameters were as follows: 120 kV, 200 mAs,
thickness: 0.9 mm; increment: 0.45 mm, and average DLP:
850 mGy
cm.
In the frontal plane 3 radiological regions of interest (ROI)
were selected: the anterior in front of the incisal foramen
(region 1), the median midway between the anterior nasal
spine and the posterior (region 2), 10 mm in front of the
posterior nasal spine of the hard palate (region 3) (fig. 1).
The images were analyzed with OsiriX software (open-source
software version 5.8.5 32-bit). The ROI were identified at
exactly the place where the cuts into the maxillaries were
performed.
Thirty ROI were obtained. One image per ROI was selected.
These images were integrated into a PowerPointW presenta-
tion (Microsoft Office PowerPoint 2011; Microsoft, Redmond,
Wash). The zoom was set at 280%. The window was centered
on 797 HU and its width was 2953 HU. None of the parameters
could be changed.
These images were analyzed by 3 radiologists and classified
into 2 groups:
 group 1 or ‘‘Open’’: the MPS was visible on more than 50%
of its length (fig. 2a and b);
 group 2 or ‘‘Closed’’: MPS was visible on less than 50% of its
length (fig. 3a and b).
When the results were not identical between the 3 radio-
logists, the classification of the ROI was determined by the
majority.
The reproducibility between the radiologists was evaluated
statistically by Fleiss’ kappa coefficient via ReCal3 (version 0.1
Alpha for 3+ coders).
Histology
ROI 1, 2 and 3 were identified after thawing. The measure-
ments were performed using a millimeter compass. The cuts
in the maxilla were made in the exact locations of the ROI
using a saw with an ‘‘EXAKT cutting system 310’’ saw. Each
slice had a thickness of between 3 and 4 mm. Specimens were
fixed in 10% neutral formalin, decalcified (Decalc, Histolab)
and embedded in paraffin. Sections of 4 micrometers thick-
ness of each paraffin block were obtained. They were stained
with the standard hematoxylin-eosin-saffron (HES) and then
scanned using the Hamamatsu digital pathology systemW
(Hamamatsu Technologies, DNanoZoomer 2.0 RS).
REVSTO-292; No of Pages 8

[(Figure_1)TD$IG] Rapid maxillary expansion in adults

Figure 1. Analysis of MSCT images. Selection of ROI exactly where the cuts into the maxilla were made.

[(Figure_2)TD$IG]

Figure 2. Analysis of MSCT images (continued): examples of ROI in the frontal plane considered as ‘‘open’’. a: from region 1; b: from region 2.

[(Figure_3)TD$IG]

Figure 3. Analysis of MSCT images (continued): examples of ROI in the frontal plane considered as ‘‘closed’’. a: from region 1; b: from region 2.

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REVSTO-292; No of Pages 8

A. Gueutier et al. Rev Stomatol Chir Maxillofac Chir Orale 2016;xxx:1-8

Histomorphometric analysis equidistant, from the nasal to the oral side of the suture and
then calculating the mean value (fig. 4).
Three sources of resistance parameters were measured: the
The OI length was calculated by measuring the total length
mean sutural width (MSW), the obliteration index (OI) and
(TL) of the MPS from the palatal mucosa to the floor of the
interdigitation index (Ii).
nasal cavity and measuring the lengths of the areas with
The histological slides were scanned (Hamamatsu DNanoZoo-
ossification bridges (OL) according to the formula:
mer 2.0 RS) and analyzed using NDP view 2, (Nanozoomer
OI = (OL  100)/TL (fig. 5).
software for digital pathology). The software was used to
To enable a quantifiable analysis of the serpentine path, and
calculate lengths and distances according to the method used
thus measure the amplitude of interdigitating the Ii parameter
by Wehrbein. The measurements were made only on one
was added in the analysis of previous histological studies. Ii
histological section of each ROI.
was obtained by the equation: TL/Direct Line (DL). DL is the
The MSW of each microsection was determined by measuring
straight line drawn between the starting point and destination
the width represented by the shortest line between
of the TL. It represents the shortest route (fig. 6).
[(Figure_4)TD$IG]the 2 maxillary bones at 10 different points, approximately

Figure 4. Histologic slide showing measurement of the mean sutural width. Green lines: intrasutural distances; black line: central sutural line or TL. Frontal
section through the midpalatal region.
[(Figure_5)TD$IG]

Figure 5. Histologic slide showing bony bridges. Black line: central sutural line is interrupted by bony bridges. Frontal section through the midpalatal region.

4
REVSTO-292; No of Pages 8

[(Figure_6)TD$IG] Rapid maxillary expansion in adults

MSW, IO and Ii were compared statistically between groups 1

and 2 by the Mann-Whitney test (free software R, version 3.1.1).
A difference was statistically significant for P < 0.05.

Figure 6. Histologic slide showing measurement of interdigitation index.
Black line: central suture line or TL; yellow line: DL.
Results
The 3 radiologists classified 27 of the 30 ROI in the same group.
Fleiss’ kappa coefficient, calculated at 0.85, showed that the
examiners were in almost complete agreement (table I).
ROI of 30, 9 were classified in group 1 and 21 in group 2 (table II).
All ROI belonging to the region 3 were considered closed. The
calculated MSW were 396.97 mm and 227.12 mm for groups 1
and 2 respectively. The OI indices were 3.098% and 9.31%
respectively. There were a ROI with OI at 0% in both group 1
and in group 2.
The averages of Ii were 1.004 and 1.086. The minimum Ii was
found in region 1 and the maximum Ii in region 3. Only 1
unidentifiable histological section, was found where the MSW
was 0 mm and the OI was equal to 100%. It belonged to region
3 (fig. 7).
We compared the mean parameters for MSW, OI and Ii and
found a statistically significant difference only for MSW.

Table I
Results of the classification of ROI by the 3 radiologists into 2 groups.
Subjects ROI Radiologist 1, group Radiologist 2, group Radiologist 3, group Final rankings
1 1 1 1 1 1
1 2 2 1 2 2
1 3 2 2 2 2
2 1 1 1 1 1
2 2 1 1 1 1
2 3 2 2 2 2
3 1 1 1 1 1
3 2 2 2 1 2
3 3 2 2 2 2
4 1 1 1 1 1
4 2 2 2 2 2
4 3 2 2 1 2
5 1 2 2 2 2
5 2 1 1 1 1
5 3 2 2 2 2
6 1 2 2 2 2
6 2 1 1 1 1
6 3 2 2 2 2
7 1 2 2 2 2
7 2 2 2 2 2
7 3 2 2 2 2
8 1 2 2 2 2
8 2 2 2 2 2
8 3 2 2 2 2
9 1 2 2 2 2
9 2 1 1 1 1
9 3 2 2 2 2
10 1 1 1 1 1
10 2 2 2 2 2
10 3 2 2 2 2

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A. Gueutier et al. [(Figure_8)TD$IG] Rev Stomatol Chir Maxillofac Chir Orale 2016;xxx:1-8

Table II
Main results of the 3 parameters in group 1 and group 2.
Group 1 Group 2
Number 9 21
Region 1 5 5
Region 2 4 6
Region 3 0 10
Mean suture width (mm) 396.97 227.12
Max suture width (mm) 1010.3 529.4
Min suture width (mm) 203.23 0
Mean obliteration index (%) 3.098 9.31
Max obliteration index (%) 9.48 100
Min obliteration index (%) 0 0
Mean interdigitation index 1.25 1.361
Max interdigitation index 1.649 2.107
Min interdigitation index 1.004 1.086

Additional results: histological analysis has identified addi-

tional interesting results. Bone banks of the MPS consisted of
lamellar bone, on which there is found a woven bone apposi-
tion corresponding to primary bone.
The MPS was mostly fibrous connective tissue with a very low
number of cells and blood vessels. It was composed of colla-
gen fibers embedded in the same way that Sharpey’s fibers
(fig. 8). They were parallel to each other and arranged in the
beam. These beams had different directions from each other
and were broken. Islets of calcifications in the center of
the suture were visible and bone spicules gave rise to banks
(fig. 9).
Discussion
MSCT allows the evaluation of width of the MPS, but does not
[(Figure_7)TD$IG]assess the other parameters, such as the obliteration and
Figure 8. Histologic slide showing the Sharpey’s fibers (zoom  40).
interdigitation indices. Therefore, it cannot be predictive of an
orthodontic or a surgical treatment.
Our interpretation of MSCT is simple and has very good
reproducibility between examiners. The choice of 50% visible
or non-visible is arbitrary. Maybe different results could be
obtained with a limit of 25% or 75%. But the interpretation
would have been more difficult and the reproducibility would
have been deteriorated. We could improve the resolution of
images, but at the cost of higher irradiation. To remain within
the conditions of common practice, we preferred to use CT
scan with a low dose of irradiation. In the same subjects, we
found areas belonging to group 1 and group 2. The aim of our
study was to compare CT and histology, not to know if a
subject was eligible for an RME or not.
[(Figure_9)TD$IG]

Figure 9. Histologic slide showing the organization of connective tissue on

Figure 7. Histologic slide showing the only synostosed ROI. polarized light (zoom  10).

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REVSTO-292; No of Pages 8
The number of subjects is low for our study. But previous
histological studies on MPS included 10 subjects in 2001 and
22 subjects in 2004 for the same team [6,7]. Persson and
Melsen worked on 24 and 60 cases respectively, but these
studies have been done 40 years ago [2,3].
Our cases are aged between 70 and 86 years old, which makes
this study an original histological analysis of the original
intermaxillary suture. There is no such study on a population
in this old-age group. The age of the population does not
correspond to the one concerned by the treatment of trans-
verse maxillary deficiency, but our results are similar to
previous studies on younger populations. The average width
of the suture is similar to previous studies. The MSW calcu-
lated in Wehrbein’s study, with a population aged 18–38 years,
was 201 mm in their ‘‘closed’’ group and was 227.12 mm in our
‘‘closed group’’ [6]. The MSW calculated in Knaup’s study, with
a population aged 18–63 years, was 211.20 mm [7]. The OI
shows the percentages of low ossification in all measurement
studies.
OI equals to 9.38% in our ‘‘closed’’ group. For Wehrbein and
Yildizhan, it is even lower: 1.3% [6]. In some previous studies,
the highest OI was 17% in the Persson’s study [3]. This confirms
that the MPS shows little or no ossification even at extreme
ages. These low figures ossification in the elderly could be
explained by osteoporosis, but our analysis of bone tissue
found no osteoporotic bone tissue on either side of the MPS.
The Ii cannot be compared to previous studies because our
study is the first histological study that quantify interdigita-
tions. It seemed necessary, as for Melsen, Wehrbein and
Knaup it appears as a major factor of resistance to the
RME [2,6,7].
We chose MSCT over cone-beam computed tomography
(CBCT). CBCT provides a better resolution on dense tissues
and lower irradiation compared to MSCT [8–10]. However, it
has major flaws: the multiplicity of devices and settings leads
to different interpretations of the results [11]. In addition, the
soft tissue resolution is poor, while the MPS is partly made up
of soft tissue.
Studies in animal models with high-performance instruments
were performed. The CBCT showed a higher resolution than
MSCT in pigs [12]. Fricke-Zech et al. compared the MPS’s
measurements of the MPS obtained by this prototype against
histological measures [13]. Recinos et al. did the same, also
using a Microfocal CT on murine cranial sutures. Their results
are promising and provide minimal differences [14].
Our study confirms that complete ossification of the MPS does
not exist. Therefore ossification is not responsible for the
resistance to the RME as is still believed in other publications.
The ossification process is incomplete when the MPS is sub-
jected to strong forces, including chewing, which are respon-
sible for the breakdown of bone bridges and collagen fibers
[15]. The Sharpey’s fibers founded in our complementary
results are certainly another resistance factor to consider.
These fibers have already been identified by Melsen, but were
Rapid maxillary expansion in adults
uninterrupted. Amongst our older subjects, they were some-
times broken. This reflects the forces exerted on the MPS [2].
Resistance to RME is due to several factors resulting in the
maturation of the MPS.
We believe that the width of the suture is not a resistance
factor but rather a marker of maturation, and its decrease
with age is a consequence of maturation. According to Fricke-
Zech et al., the width of the suture has a high prognostic value
in the treatment strategy [13].
The interdigitations seem to be the consequence of the onset
of bone apposition, bone spicules and bone bridges. Ii also
demonstrates the progress of maturation, but it is difficult to
quantify without discrimination on the basis of our results.
For Wertz, the circumaxillary sutures are the resistance factor
[16]. For us, they are a secondary factor compared to the MPS’
own resistance factors. However, they must be taken into
account, because the RME induces changes on the quanti-
fiable circumaxillary sutures in MSCT [17]. For Korbmacher
et al., bone density is the main factor of RME resistance.
Indeed, in an analysis in humans using micro-CT, amongst the
various parameters compared in 3 age groups, only bone
density showed any significant difference [18]. We tried to
measure the density in the center and the margins of suture,
but the resolution of our images did not allow us to obtain
reliable measurements. We obtained very large density dif-
ferences between 2 measurement points located nearby.
To anticipate possible RME treatment failure, all of the sour-
ces of resistance must be known. These seem difficult to
identify by the imagery used in current practice. Using compu-
ter models such as finite element analysis could provide
answers. But according to a recent review of the literature,
a more representative method of the intermaxillary suture in
finite element simulations would be required, rather than
those currently used [19]. This method could also incorporate
the circumaxillary sutures that we have not considered in our
study.
Disclosure of interest
The authors declare that they have no competing interest.
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