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
夽
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).
夽 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/).
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
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).
Figure1 Multiplanarimages(A)sagittal,(B)axialand(C)coronal,withcontrastsettingsoptimizedforviewingthesofttissues ofthenose.
Figure2 Repositioningtheheadusingtheprogram’shorizontalandverticalreferencelinesinthe(A)sagittal,(B)axialand(C) coronalplanes.
Al
rAl
LLength: 3.705 cm
A
B
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 cmA
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
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.
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
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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