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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Short-term

evaluation

of

tegumentary

changes

of

the

nose

in

oral

breathers

undergoing

rapid

maxillary

expansion

Fauze

Ramez

Badreddine

,

Reginaldo

Raimundo

Fujita,

Mario

Cappellette

Jr.

UniversidadeFederaldeSãoPaulo(UNIFESP),EscolaPaulistadeMedicina(EPM),DepartamentodeOtorrinolaringologia ---CirurgiadeCabec¸aePescoc¸o,SãoPaulo,SP,Brazil

Received12March2017;accepted28May2017 Availableonline26June2017

KEYWORDS Nose; Soft-tissue; Maxillaryexpansion; Multislicecomputed tomography Abstract

Introduction:Rapidmaxillaryexpansionisanorthodonticandorthopedicprocedurethatcan change theformandfunction ofthenose. The softtissueofthenoseanditschanges can influencetheestheticsandthestabilityoftheresultsobtainedbythisprocedure.

Objective:Theobjectiveofthisstudywastoassessthechangesinnosedimensionsafterrapid maxillaryexpansioninoralbreatherswithmaxillaryatresia,usingareliableandreproducible methodologythroughcomputedtomography.

Methods:A total of30 mouth-breathing patients withmaxillary atresiawere analyzed and dividedintoatreatmentgroupwhounderwentrapidmaxillaryexpansion(20patients,10of whichweremaleand10female,withaMAof8.9yearsandaSDof2.16,rangingfrom6.5to 12.5years)andaControlGroup(10patients,5ofwhichweremaleand5female,withaMA

of9.2years,SDof2.17,rangingfrom6.11to13.7years).Inthetreatmentgroup,multislice computedtomography scanswereobtainedatthestartofthetreatment(T1) and3months afterexpansion(T2).Thepatientsofthecontrolgroupweresubmittedtothesameexamsat thesameintervalsoftime.Fourvariablesrelatedtosofttissuestructuresofthenosewere analyzed(alarbasewidth,alarwidth,heightofsofttissueofthenoseandlengthofsofttissue ofthenose),andtheoutcomesbetweenT1andT2werecomparedusingOsirixMDsoftware.

Results:IntheTG,thesofttissuesofthenoseexhibitedsignificantincreasesinallvariables studied(p<0.05),whereas,changesdidnotoccurinthecontrolgroup(p>0.05).Inthe treat-mentgroup,meanalarbasewidthincreasedby4.87%(p=0.004),meanalarwidthincreased by4.04%(p=0.004),meanheightofthesofttissuesofthenoseincreasedby4.84%(p=0.003) andmeanlengthofthesofttissuesofthenoseincreasedby4.29%(p=0.012).

Pleasecitethisarticleas:BadreddineFR,FujitaRR,CappelletteJrM.Short-termevaluationoftegumentarychangesofthenoseinoral

breathersundergoingrapidmaxillaryexpansion.BrazJOtorhinolaryngol.2018;84:478---85.

Correspondingauthor.

E-mail:dr.fauze@hotmail.com(F.R.Badreddine).

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2017.05.010

1808-8694/©2017Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

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Conclusion: Inshort-term,rapidmaxillaryexpansionprovidedastatisticallysignificantincrease inthedimensionsofthesofttissuesofthenose.

© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). PALAVRAS-CHAVE Nariz; Tecidosmoles; Expansãomaxilar; Tomografia computadorizada multislice

Avaliac¸ãoemcurtoprazodasalterac¸õestegumentaresdonarizemrespiradoresorais submetidosàexpansãorápidadamaxila

Resumo

Introduc¸ão: A expansãorápidada maxilaéum procedimentoortodôntico e ortopédicoque podealteraraformaeafunc¸ãodonariz.Ostecidosmolesdonarizesuasalterac¸õespodem influenciarnaestéticaenaestabilidadedosresultadosobtidosporesseprocedimento.

Objetivo: Oobjetivodesseestudofoiavaliarasalterac¸õesnasdimensõesdonarizapós expan-são rápida damaxila em respiradores orais com atresia maxilar, usando uma metodologia confiávelereprodutívelcomoauxíliodetomografiacomputadorizada.

Método: Umtotalde30 pacientesrespiradoresoraiscomatresiamaxilarforamavaliadose divididosemumgrupodetratamento,submetidosàexpansãorápidadamaxila(20pacientes, 10dosquaisdosexomasculinoe10dosexofeminino,commédiadeidadede8,9anoseDPde 2,16,variandode6,5a12,5anos)eumgrupocontrole(10pacientes,sendo5dosexomasculino e5dosexofeminino,commédiadeidadede9,2anos,DPde2,17,variandode6,11a13,7anos). Nogrupotratado,foramrealizadosexamesdetomografiacomputadorizadamultislicenoinício do tratamento(T1) e3mesesapósaexpansão(T2).Ospacientesdogrupo controleforam submetidos aosmesmos examesnos mesmosintervalos detempo. Foramanalisadas quatro variáveisrelacionadasàsestruturasdostecidosmolesdonariz(larguradabasealar,largura alar,alturadotecidomoledonarizecomprimentodotecidomoledonariz)eosresultados entreT1eT2foramcomparados,utilizando-seosoftwareOsirixMD.

Resultados: Nogrupotratado(GT),ostecidosmolesdonarizapresentaramaumentos significa-tivosemtodasasvariáveisestudadas(p<0,05),enquantoissonãoocorreunoGC(p>0,05).No GT,alarguramédiadabasealaraumentou4,87%(p=0,004),alarguramédiaalaraumentou 4,04% (p=0,004),aalturamédiados tecidosmoles donarizaumentou4,84%(p=0,003)eo comprimentomédiodostecidosmolesdonarizaumentou4,29%(p=0,012).

Conclusão:Acurtoprazo,aexpansãorápidadamaxilaproporcionouumaumento estatistica-mentesignificativonasdimensõesdostecidosmolesdonariz.

© 2017 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

and

background

Maxillary atresia is considered a form of skeletal defor-mitycharacterizedbyadiscrepancyinthemaxilla/mandible relationshipinthetransverseplanewhichmayleadtoa pos-terior crossbite.1,2 This clinical condition can causemany

problemssuchasdevelopmentalabnormalitiesoftheface andofocclusion,mouthbreathing,3,4prematureteethloss

andevenposturalproblemsinvolvingirregulardevelopment ofthebody.5---7

Angell,1,2 in 1860, wasthe firstresearcher to describe

thepossibilityofopeningthemid-palatalsuturetoachieve transversemaxillarycorrection,however,itwasHass8,9who

publishedthefirststudiesthatclarifiedtherealbenefitsof thistreatment modalities.FromHass’studies theutilized methodsforrapidmaxillaryexpansionbecameclearerand morestandardized.10

Since then, innumerable experiments have been con-ducted demonstrating the importance of rapid maxillary expansion(RME)infacialdevelopmentandocclusion.

In his previous studies, Haas pointed out the positive results/aspectsinthenasalcavityafterusingtheappliance. Lateron,itwasprovedthat,although therewasanarrow anatomicrelationship between the maxilla and the nasal cavity,11RMEwascapableofchangingthisnasalphysiology

andanatomy.7,11,12Inmanycases,itcouldimprovebreathing

patternsbyreducingtheresistanceofthenasalairway,7,13

andthussubstitutingnasalbreathingforamouthbreathing patterninmanypatients.

For many years, the skeletal effects of RME were the mainfocusoftheresearchersbut,somestudies indicated thatthe soft tissues of the face,including the nose, fol-lowedtheskeletalchangesaftertheprocedure,13,14causing

possibleeffectsonfacialaesthetics15,16 andthus

interfer-inginthestabilityoftheresultsachievedthroughskeletal expansion.13,14

Bergeretal.15 publishedthefirstreportsonchangesto

nasalsofttissues,usingdigitalphotographytodemonstrate asignificantincreaseof2mminthewidthofthenoseafter RME. This contrasted with results published by Johnson

(3)

etal.17 whoassessedthe widthofnasal softtissues using

high precision calipers and did not find significant differ-encesbetweentheperiods,beforeandafterRME.Karaman et al.14 conducted studies using lateral cephalometry,

reporting that the length of the soft tissue of the nose tended to increase in line with the forward orthopedic displacement of the maxilla (Point A) during RME. Kilic¸ etal.18 alsoemployed lateralcephalometry and reported

similarresults.

Kimetal.19andKulbershetal.13publishedthefirststudy

thatevaluatedchangesofthesofttissuesofthenoseusing aconebeamcomputedtomography(CBCT),whichwas con-sideredthemostprecisediagnosticmethodforthistypeof research.11,13Bothstudiesshowedthatthewidthofthesoft

tissuesofthenoseunderwentasignificantincrease. Magnusson etal.16 employedspiralcomputed

tomogra-phy(CT)toassessthenasalsofttissuesanddocumentedthat alldimensions increasedwithforward and downward dis-placementofsofttissues.Notwithstanding,theyconcluded thatthelargestchangeswereinthewidthofthenose.In oneofthemostrecentstudiesconductedusingCBCT,Yilmaz andKucukkeles20 reported statisticallysignificant changes

inthe widthof the nose,but, in agreementwithfindings reportedbyBergeretal.,15theincreaseinlengthprovedto

bewithoutclinicalorestheticrelevance.

Itcanbenoticed thattherearefew studiesinthe sci-entificliteraturereportingthedimensionalchangesofthe softtissues of thenose afterRME,increasing our motiva-tioninthesearchformoreresearchthatcanaddusefuland pertinentinformationtothetheme.

Theobjectivesofthisstudyweretoevaluatethe dimen-sional changes of the nasal soft tissues after RME in all threeplanes(height, width and length)by using a multi-slicecomputedtomography(CT).Andsecond,todetermine whetherthechanges really tookplace,in whatextension andifthereisstatisticalsignificancetojustifyallthe con-cerninorthodontics/orthopedicsclinicalpracticewiththe effectsoftheRMEprocedureonnasalsofttissues.

Materials

and

methods

This was a retrospective study of 30 patients divided in 2 groups: a Treatment Group (TG), underwent RME (20 patients, 10 of which were male and 10 female, with a

MAof8.9yearsandaSDof2.16,rangingfrom6.5to12.5 years)and a Control Group (CG) (10patients, 5 of which weremaleand5female,withaMAof9.2years,SDof2.17, rangingfrom6.11to13.7years).Allpatientshadmaxillary atresia (sufficient level of maxillary atresia to indicate RME)andmouthbreathing,diagnosedbyotolaryngologists (mouth breathing) and orthodontists (maxillary atresia). ThepatientsoftheTGweretreatedwiththeaidofaHyrax maxillaryexpanderfollowingtheclinic’sstandardprotocol of six activations in the early treatment and two daily activations, which was conducted until the upper bucal alveolaredgebecametransverselycompatibletotheWALA edge(Areaofthegreatertransversewidth,atthealveolar dental junction of the mandible). Computed tomography scansweretakenat twodifferent times:(T1)beforeRME andafter3months wearingthe device(T2).The patients of the CG underwent the same CT examinations (T1 and

Table1 Softtissuelandmarks.

Nasion(N) Pointonthesofttissuemidlinethat directlycoversthehardtissueinthe directionoftheskeletalNasion(N). Pronasale(Prn) Themostprominentpointofthenose

locatedonthemidline.

Alar(Al) Themostlateralpointoftheoutsideof eachnostril.

Alarcurvature (Ca)

Pointofinsertionintothesofttissueat eachalarbase.

Subnasale(Sn) Themidpointbetweenthejunctionof thelowermarginofthenasalseptum andtheupperlip,onthemidline

T2)atsimilarperiodsoftimetothoseintheTG(3months betweenthem).ItisimportanttoclarifythatallCTscans where acquired with proper prescription and pertinent authorization, and since this research was controlled withan already-existing database, nohuman beings were exposedtoany quantityof ionizingration radiationsolely forthepurposesofconductingthisstudy.Allpatientswere evaluated by a multi-disciplinary team and the diagnoses were madethrough astandardized questionnaire,as well as by a otolaryngological and orthodontic evaluation. Syndromic patients or patients with craniofacial abnor-malities suchasPierreRobin andTreacherCollins,among others, and patients with dental or periodontal changes were excluded from the study. This study was approved by the Committee for Ethics in Institutional Research (registered under n◦ 164761), and by Clinical Trial (ID: CRB-ORTO3).

Thewidth,heightandlengthofnasalsofttissueswere measured using anatomiclandmarksdefined in theglobal literature,16,20---22 which are listed in Table 1 with their

descriptions.

MeasurementsbeforeRMEandafterRME,intheTG,and measurementsbeforeT1andT2,intheCG,weretakenusing OsiriXMDsoftware(FDA approved,version1.4.2; Pixmeo, Geneva,Switzerland),whichoffersthepossibilityof acquir-ingmultiplanarslices(sagittal,axialandcoronal)fromthe CTimages.Usingtheprogram’sdedicatedtools,itispossible todefinetheoptimumsettingsforcontrast,selectdifferent density filtersandapplytransparency,resultinginperfect visualizationofthesofttissuesonsagittal,axialandcoronal images(Fig.1).

In order to guarantee accurate measurements between the chosen landmarks, the patients’ headswere repositioned before taking the measurements, using the program’shorizontalandverticalreferencelines,following methodologydescribedbyCevidanesetal.23(Fig.2).

Thewidth ofthe softtissueof thenose wasmeasured on axial images at two different points, first by measur-ingthelineardistance (inmm) betweenpointsAlr andAlL

(alarwidth---Fig.3)andsecondbymeasuringthedistance betweenpointsCarandCaL(alarbasewidth---Fig.4).Height

wasmeasuredonsagittalimagesbytakingthedistance(in mm) between points N and Sn (Fig. 5), and length, also measured on sagittalimages, wasmeasured asthe linear distance(inmm)frompointPrntopointSn(Fig.6).

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Figure1 Multiplanarimages(A)sagittal,(B)axialand(C)coronal,withcontrastsettingsoptimizedforviewingthesofttissues ofthenose.

Figure2 Repositioningtheheadusingtheprogram’shorizontalandverticalreferencelinesinthe(A)sagittal,(B)axialand(C) coronalplanes.

Al

r

Al

L

Length: 3.705 cm

A

B

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Car CaL

Length: 3.997 cm

A

B

Figure4 Measuringthealarbasewidthatthesofttissueinsertiononanaxialimage.ConnectingpointsCarandCaL.

N’

Length: 4.978 cm

A

B

Sn

Figure5 Measuringtheheightofthesofttissueofthenoseonasagittalimage.ConnectingpointsNandSn.

Prn

Sn

Length: 1.786 cm

A

B

Figure6 Measuringthelengthofthesofttissueofthenoseonasagittalimage.ConnectingpointsPrnandSn.

Statisticalanalysis

Analysisandstatisticaltreatmentofdatawasaccomplished usingtheStatisticalPackagefortheSocialSciences(SPSS), version 22 for Windows.24 Measurement results are

pro-videdinmillimeters(mm)andexpressedasMeans(M)and standarddeviationsintheformM±SD.

Toverifythesuitabilityofthesample,thedimensionof theeffect(d)wascalculatedwithasignificancelevelof5% (˛=0.05,being ˛the Type Ierror) and onepower of the test(1−ˇ,beingˇtheTypeIIerror)of80%.Allcalculations

were made with the software G*Power25 and the

classifi-cationstothedimensioneffectproposedbyCohen(1992):

d=0.2 --- small effect; d=0.5 --- médium effect; d=0.8 ---largeeffect,weregivenconsideration.Thesample(n=20) securedthe identification ofthe small/médium(d=0.46), with a effect power of 80% and a significance level of5%.

NormalityofthedatawasverifiedusingtheShapiro---Wilk test.Sincenormalitywasconfirmedforallvariables, para-metric tests were used for statistical analyses: Student’s

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Table2 Resultsofthetestsofnormalityofdata:significancevalues(p)accordingtotheShapiro---Wilktest.

Variable 1stmeasurement 2ndmeasurement

BeforeRME (p) AfterRME (p) BeforeRME (p) AfterRME (p)

Alarbasewidth 0.886 0.378 0.684 0.850

Alarwidth 0.980 0.215 0.657 0.233

Heightofsofttissueofthenose 0.115 0.097 0.245 0.093 Lengthofsofttissueofthenose 0.213 0.489 0.086 0.384

differencesbetweenmeasurementstakenbeforeandafter rapidmaxillaryexpansion(RME).

Intra-examinerreliabilitywasevaluatedusingStudent’s t test for paired samples and intraclass correlation coef-ficients(ICC). The results of statistical tests werejudged againstasignificancelevelof5%.

Forthe analysisof thecomparisonbetween T1and T2 valuesinbothgroups,andforthecomparisonbetweenthe groups,theStudent’st-testforpairedsampleswasused.

Results

Thesignificancevalues(p)fromtheShapiro---Wilktestused toanalyzenormalityofdataweregreaterthanorequalto 0.05 for allvariables. Onthis basis thenullhypothesis of thetestwasnotrejectedtoasignificantlevelof5%andit wasthereforeassumedthatalldatahadnormaldistribution (Table2).

For the purposes of intra-examiner reliability assess-ment,themeasurementsofCTscanstakenbeforeandafter RMEwererepeatedbythesameexaminer30daysafterthe firstmeasurementswereregistered.AllCT’swerenumbered without the observerknowledge if hewas measuring the grouppreorpostRME.

After allmeasurements, everyCT wasorganized prop-erly initscorresponding group.The results ofStudent’s t

test forpaired samplesshowedthattherewereno statis-ticallysignificantdifferences(p>0.05)betweenthemeans ofthefirstandsecondmeasurements(repetitionwitha30

dayinterval)foranyofthevariablestested,eitherforCT scansconductedbeforeRMEorforCTscansafterRME.For allvariablesICCvaluesweregreaterthan0.95(closeto1), indicatingexcellentconsistencybetweenresultsforthefirst andsecondmeasurements(Table3).Takentogether,these resultsguaranteeexcellentintra-examinerreliabilityforthe measurementstaken.

AnalysisoftheeffectsofRMEin theTGandthe analy-sisoftheeffectsbetweenT1andT2intheCG,aswellas theanalysisof theeffects betweenthetwogroups, were takenusingthefirstsetofmeasurementsfromscans,and theresultsoftheseanalysisarelistedinTable4.

Aglobalevaluationoftheresultsshowedthattherewas, intheTG,astatisticallysignificantincreaseinallfour mea-surementsfrombeforeRMEtoafterRME(p<0.05),whereas intheCGnosignificant changeswasobservedbetweenT1 andT2times(p>0.05).Furthermore,comparisonbetween both groups showed a statistically significant difference (p<0.05),revealingthatRMEinducedincreasesinthe val-uesofalarbasewidth,alarwidth,heightofsofttissueof thenoseandlengthofsofttissueofthenose.

Themeanvalueforalarbasewidth,intheTG,increased significantly(p=0.004)from33.36±1.95mmbeforeRMEto 34.99±1.90mmafterRME,whichisequivalenttoamean increaseof4.87%.IntheCG,nosignificantdifferencewas observed(p=0.938)betweenmeansofT1(32.85±1.86)and T2(32.87±2.12).

ThemeanAlarwidthmeasurement,intheTG,increased 4.04%,from33.65±2.54mmto35.01±2.29mm,whichwas a statistically significant increase (p=0.004). In the CG,

Table3 Resultsoftestofintra-examinerreliability:Student’sttestforpairedsamplesandintraclasscorrelationcoefficients (measurementsinmm).

Variable 1stmeasurement 2ndmeasurement Difference pa ICCb

TomographybeforeRME

Alarbasewidth 33.11±1.87 33.06±1.85 −0.04 0.700 0.967

Alarwidth 33.25±2.24 33.16±2.41 −0.09 0.480 0.970

Heightofsofttissueofthenose 49.03±4.08 48.96±3.88 −0.07 0.659 0.984

Lengthofsofttissueofthenose 15.88±1.54 15.74±1.49 −0.14 0.203 0.953

TomographyafterRME

Alarbasewidth 33.93±2.24 33.81±2.08 −0.12 0.299 0.973

Alarwidth 33.77±2.63 33.73±2.70 −0.04 0.688 0.985

Heightofsofttissueofthenose 49.82±4.16 49.97±4.19 0.16 0.497 0.970

Lengthofsofttissueofthenose 16.33±1.94 16.32±1.94 −0.01 0.940 0.950

Resultsexpressedasmean±standarddeviation.

a p,significanceaccordingtoStudent’sttestforpairedsamples. b Intraclasscorrelationcoefficients.

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Table4 ComparisonbetweenmeasurementsbeforeRMEandafterRMEandbetweenTreatmentGroup(TG)andControlGroup (CG)(measurementsinmm).

Variable Group BeforeRME AfterRME Differencebeforeafter pa

(beforeRME−after RME)

Mean %

Alarbasewidth TG 33.36±1.95 34.99±1.90 1.62 +4.87% 0.004

CG 32.85±1.86 32.87±2.12 0.03 −0.08% 0.938

pb(betweengroups) 0.550 0.030

Alarwidth TG 33.65±2.54 35.01±2.29 1.36 +4.04% 0.004

CG 32.85±1.95 32.52±2.42 −0.33 −0.99% 0.362

pb(betweengroups) 0.438 0.030

Heightofsofttissueof thenose

TG 48.51±4.22 50.98±4.32 2.47 +4.84% 0.003

CG 46.77±4.06 46.92±3.94 0.15 +0.32% 0.228

pb(betweengroups) 0.509 0.028

Lengthofsofttissueof thenose

TG 16.52±1.53 17.23±1.84 0.71 +4.29% 0.001

CG 15.23±1.33 15.43±1.66 0.19 +1.27% 0.491

pb(betweengroups) 0.061 0.034

Resultsexpressedasmean±standarddeviation.

ap,significanceaccordingtoStudent’sttestforpairedsamples(differencesbetweenbeforeandafter). b p,significanceaccordingtoStudent’sttestforindependentsamples(differencesbetweenTGandCG).

nosignificantdifferencewasobserved(p=0.362)between meansofT1(32.85±1.95)andT2(32.52±2.42).

The height of the soft tissue of the nose, in the TG, increased significantly (p=0.003), from 48.51±4.22mm before RME to 50.98±4.32mm after RME, which is the equivalentof4.84%.IntheCG,nosignificantdifferencewas observed(p=0.228)betweenmeansofT1(46.77±4.06)and T2(46.92±3.94).

The mean length of the soft tissue of the nose, in the TG, increased by 4.29%, from 16.52±1.53mm to 17.23±1.84mm,whichisastatisticallysignificantincrease (p=0.001).IntheCG,nosignificantdifferencewasobserved (p=0.491) between means of T1 (15.23±1.33) and T2 (15.43±1.66).

Discussion

Since the first reports were published by Angell1,2 and

Haas,8---10 numerousstudieshaveclearlydemonstratedthat

RMEiscapableofalteringthephysiologyandanatomyofthe nasalcavity.7,11---13

Thesofttissuesoftheface,includingthenose,havebeen recentlyinvestigatedbecauseoftheestheticconsequences andalsoinrelationtothestabilityoftheresultsachieved usingRME.13---16

The first studies, focused on changes to nasal soft tissues, were conducted, using measurements on dig-ital photographs, before and after RME,15 directly on

patients’facesusinghigh-precisioncalipers17 orondigital

cephalometry.14,18Thesestudiesanalyzedonlythechanges

to width15,17 and length.14,18 With regard to soft tissue

width,Bergeretal.15foundameanincreaseof2mmafter

RME. Our study demonstrated similar results with mean increasesof1.62mminalarbasewidthand1.36mminalar width.Bothoftheseresultswerestatisticallysignificant,in

contrastwithresultsreportedbyJohnsonetal.,17whoalso

identifiedincreasesinsoft tissuewidth, but,accordingto their results, without statistical significance. With regard to the length of the soft tissue of the nose, our study demonstrateda significantmean increaseof 4.29%among patients after RME,which is inagreement withoutcomes publishedbyKaramanetal.14 andKilic¸etal.18

Studiesundertakenusingconebeamcomputed tomogra-phy (CBCT),13,19,20 showedthat RMEresulted insignificant

increasesin thetransversal dimensions of thesoft tissues ofthenose,whichagreeswithourresults,but,incontrast withourfindings,theyfoundthatincreasesinlengthwere notstatistically relevant.This discrepancy couldoccurred because the CBCT has lower radiation dose and is not recommendedforsofttissuemeasurement.However, Mag-nussenetal.16usedspiralcomputedtomography(CT)scans

to measurenasal soft tissues, in commonwith ourstudy. Theseauthorsconcludedthatalthoughtherewerechanges to all of the dimensions of the nose, only differences in widthmeasurementsweresignificant,whichdoesnotagree withourresults,sincewedemonstratedstatistically signif-icant differencesin allvariables studied. Webelieve that thesedifferencesintheresultsoccurredbecauseMagnussen etal.carriedouttheirstudywithpatientswhounderwent surgicallyassistedRME,withpatientsoutsideofthefacial skullgrowthphase,whileourstudywasperformedonlywith orthopedicRMEinpatientswhichwereintheactivephase ofgrowth.

Practicallynoneofthestudiescitedassessedtheheight of the soft tissueof the nose. The majority only studied transversechangesandfewmeasuredlength.Inourstudy, wealsoinvestigatedthepossibilityofchangestotheheight ofthesofttissueofthenose,findingthattherehadbeena significantincrease,ofapproximately4.84%,afterRME.

Even when studying patients in the growth phase,we believe that the changes observed in our study, occurred

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solelyduetotheaction ofRME,sincethetimeof evalua-tionbetweenT1andT2timeswasonly3months,wouldbe insufficient for a significant interferenceof the growthin theobtainedresults.

Weshouldmakeclearthatallpatientsthattookpartof thisresearchunderwenttheCTexamsin thesameplace, with the same equipment and with the same operator, respectingthe ALARA principle26,27 (As Low As Reasonably

Achievable)toeachpatient.

Itisalsoimportanttoclarifythat,aftertheendofthe study,thepatientsoftheCGwereproperlytreatedwiththe sameproceduresoftheTG,withoutanyprejudicetothem, duetothesmalltimeof3monthsbetweenT1andT2times. Ourstudyutilizedanalreadyexistingdatabasewiththe pertinentauthorizationsand approvedby theethics com-mittee.

Conclusions

Mouth breathing children after rapid maxillary expansion showedashort-termstatisticallysignificantincreasein mea-surements of alar base width, at the point of soft tissue insertion,alarwidth,heightofsofttissueof thenose and lengthofsofttissueofthenose.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

Acknowledgements

There were not any organizations that funded our manuscript.Itwasfundedbyourselves.

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