Evaluation of mandibular changes after rapid maxillary expansion: a CBCT study in youngsters with unilateral posterior crossbite using a surface-to-surface matching technique



The purpose of this study was to evaluate mandibular asymmetry in youngsters with posterior unilateral crossbite (PUXB), through cone-beam computed tomography and reverse engineering technique, before and after rapid maxillary expansion (RME) treatment.

Materials and methods

Forty cone-beam computed tomography (CBCT) images were obtained from all patients at two time points, namely T0 acquired before the placement of a Hyrax expander and T1 after appliance removal. The CBCT scans were segmented and volume rendered into a surface there-dimensional (3D) mesh model. Thereafter, mandibular models were digitally registered by using a “best-fit” algorithm. Surface and volumetric changes, between T0 and T1, were compared by using Student’s t tests.


A slight increase of 0.45 cm3 of the total mandibular volume was found at T1 when compared with T0 (p < 0.001). The mandibular hemi-volume on the crossbite side (CB) was slightly smaller than the non-crossbite side both at T0 and T1. However, the mean differences of hemi-volume from the CB (crossbite) and non-CB side between T0 and T1 show a decrease of 0.26 cm3 (p < 0.001). Findings for the surface-to-surface deviation analysis demonstrated a fine percentage of matching at T0 which slightly improved at T1 (p < 0.001).


Youngsters affected by PUXB showed a very slight and not statistically significant volumetric and morphological asymmetry between CB side and non-CB side at T0. However, the change in mean differences of 0.26 cm cannot be considered clinically relevant.

Clinical relevance

Mandibles in young PUXB patients exhibit only a very mild mandibular asymmetry. Although the statistically significant mean change found right after RME removal cannot be considered clinically relevant, a more consistent sample and a longer follow-up could be of interest in explaining the short-term findings.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7


  1. 1.

    Bjoerk A, Krebs A, Solow B (1964) A method for epidemiological registration of malocclusion. Acta Odontol Scand 22:27–41

    Article  Google Scholar 

  2. 2.

    Iodice G, Danzi G, Cimino R, Paduano S, Michelotti A (2016) Association between posterior crossbite, skeletal, and muscle asymmetry: a systematic review. Eur J Orthod 38:638–651. https://doi.org/10.1093/ejo/cjw003

    Article  PubMed  Google Scholar 

  3. 3.

    Kutin G, Hawes RR (1969) Posterior cross-bites in the deciduous and mixed dentitions. Am J Orthod 56:491–504

    Article  Google Scholar 

  4. 4.

    Egermark-Eriksson I, Carlsson GE, Magnusson T, Thilander B (1990) A longitudinal study on malocclusion in relation to signs and symptoms of cranio-mandibular disorders in children and adolescents. Eur J Orthod 12:399–407

    Article  Google Scholar 

  5. 5.

    Zhu JF, Crevoisier R, King DL, Henry R, Mills CM (1996) Posterior crossbites in children. Compend Contin Educ Dent 17:1051–1054 1056, 1058

    PubMed  Google Scholar 

  6. 6.

    Schroder U, Schroder I (1984) Early treatment of unilateral posterior crossbite in children with bilaterally contracted maxillae. Eur J Orthod 6:65–69

    Article  Google Scholar 

  7. 7.

    Baka ZM, Akin M, Ucar FI, Ileri Z (2015) Cone-beam computed tomography evaluation of dentoskeletal changes after asymmetric rapid maxillary expansion. Am J Orthod Dentofac Orthop 147:61–71. https://doi.org/10.1016/j.ajodo.2014.09.014

    Article  Google Scholar 

  8. 8.

    Rilo B, da Silva JL, Mora MJ, Cadarso-Suarez C, Santana U (2008) Midline shift and lateral guidance angle in adults with unilateral posterior crossbite. Am J Orthod Dentofac Orthop 133:804–808. https://doi.org/10.1016/j.ajodo.2006.05.046

    Article  Google Scholar 

  9. 9.

    Veli I, Uysal T, Ozer T, Ucar FI, Eruz M (2011) Mandibular asymmetry in unilateral and bilateral posterior crossbite patients using cone-beam computed tomography. Angle Orthod 81:966–974. https://doi.org/10.2319/022011-122.1

    Article  PubMed  Google Scholar 

  10. 10.

    Langberg BJ, Arai K, Miner RM (2005) Transverse skeletal and dental asymmetry in adults with unilateral lingual posterior crossbite. Am J Orthod Dentofac Orthop 127:6–15; discussion 15–6. https://doi.org/10.1016/j.ajodo.2003.10.044

    Article  Google Scholar 

  11. 11.

    O'Byrn BL, Sadowsky C, Schneider B, BeGole EA (1995) An evaluation of mandibular asymmetry in adults with unilateral posterior crossbite. Am J Orthod Dentofac Orthop 107:394–400

    Article  Google Scholar 

  12. 12.

    Talapaneni AK, Nuvvula S (2012) The association between posterior unilateral crossbite and craniomandibular asymmetry: a systematic review. J Orthod 39:279–291. https://doi.org/10.1179/1465312512z.00000000041

    Article  PubMed  Google Scholar 

  13. 13.

    Ferro F, Spinella P, Lama N (2011) Transverse maxillary arch form and mandibular asymmetry in patients with posterior unilateral crossbite. Am J Orthod Dentofac Orthop 140:828–838. https://doi.org/10.1016/j.ajodo.2011.08.003

    Article  Google Scholar 

  14. 14.

    Kilic N, Kiki A, Oktay H (2008) Condylar asymmetry in unilateral posterior crossbite patients. Am J Orthod Dentofac Orthop 133:382–387. https://doi.org/10.1016/j.ajodo.2006.04.041

    Article  Google Scholar 

  15. 15.

    Uysal T, Sisman Y, Kurt G, Ramoglu SI (2009) Condylar and ramal vertical asymmetry in unilateral and bilateral posterior crossbite patients and a normal occlusion sample. Am J Orthod Dentofac Orthop 136:37–43. https://doi.org/10.1016/j.ajodo.2007.06.019

    Article  Google Scholar 

  16. 16.

    Lam PH, Sadowsky C, Omerza F (1999) Mandibular asymmetry and condylar position in children with unilateral posterior crossbite. Am J Orthod Dentofac Orthop 115:569–575

    Article  Google Scholar 

  17. 17.

    Pinto AS, Buschang PH, Throckmorton GS, Chen P (2001) Morphological and positional asymmetries of young children with functional unilateral posterior crossbite. Am J Orthod Dentofac Orthop 120:513–520. https://doi.org/10.1067/mod.2001.118627a

    Article  Google Scholar 

  18. 18.

    Spampinato C, Pino C, Giordano D, Leonardi R (2012) Automatic 3D segmentation of mandible for assessment of facial asymmetry

  19. 19.

    Halicioglu K, Celikoglu M, Yavuz I, Sekerci AE, Buyuk SK (2014) An evaluation of condylar and ramal vertical asymmetry in adolescents with unilateral and bilateral posterior crossbite using cone beam computed tomography (CBCT). Aust Orthod J 30:11–18

    PubMed  Google Scholar 

  20. 20.

    Illipronti-Filho E, Fantini SM, Chilvarquer I (2015) Evaluation of mandibular condyles in children with unilateral posterior crossbite. Braz Oral Res 29:49. https://doi.org/10.1590/1807-3107BOR-2015.vol29.0049

    Article  PubMed  Google Scholar 

  21. 21.

    Cardinal L, Martins I, Gribel BF, Dominguez GC (2019) Is there an asymmetry of the condylar and coronoid processes of the mandible in individuals with unilateral crossbite? Angle Orthod 89:464–469. https://doi.org/10.2319/052518-398.1

    Article  PubMed  Google Scholar 

  22. 22.

    Evangelista K, de Oliveira CFP, de Almeida BL, Avelino MAG, Cevidanes LHS, de Oliveira Ruellas AC, Valladares-Neto J, Silva MAG (2020) Three-dimensional assessment of craniofacial asymmetry in children with transverse maxillary deficiency after rapid maxillary expansion: a prospective study. Orthod Craniofac Res. https://doi.org/10.1111/ocr.12370

  23. 23.

    Jaju PP, Jaju SP (2015) Cone-beam computed tomography: time to move from ALARA to ALADA. Imaging Sci Dent 45:263–265. https://doi.org/10.5624/isd.2015.45.4.263

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    Kavand G, Lagravere M, Kula K, Stewart K, Ghoneima A (2019) Retrospective CBCT analysis of airway volume changes after bone-borne vs tooth-borne rapid maxillary expansion. Angle Orthod 89:566–574. https://doi.org/10.2319/070818-507.1

    Article  PubMed  Google Scholar 

  25. 25.

    Pham V, Lagravere MO (2017) Alveolar bone level changes in maxillary expansion treatments assessed through CBCT. Int Orthod 15:103–113. https://doi.org/10.1016/j.ortho.2016.12.002

    Article  PubMed  Google Scholar 

  26. 26.

    Digregorio MV, Fastuca R, Zecca PA, Caprioglio A, Lagravere MO (2019) Buccal bone plate thickness after rapid maxillary expansion in mixed and permanent dentitions. Am J Orthod Dentofac Orthop 155:198–206. https://doi.org/10.1016/j.ajodo.2018.03.020

    Article  Google Scholar 

  27. 27.

    Forst D, Nijjar S, Flores-Mir C, Carey J, Secanell M, Lagravere M (2014) Comparison of in vivo 3D cone-beam computed tomography tooth volume measurement protocols. Progr Orthod 15. https://doi.org/10.1186/s40510-014-0069-2

  28. 28.

    Leonardi R (2019) Cone-beam computed tomography and three-dimensional orthodontics. Where we are and future perspectives. J Orthod 46:45–48. https://doi.org/10.1177/1465312519840029

    Article  PubMed  Google Scholar 

  29. 29.

    Leonardi R, Muraglie S, Bennici O, Cavallini C, Spampinato C (2019) Three-dimensional analysis of mandibular functional units in adult patients with unilateral posterior crossbite: a cone beam study with the use of mirroring and surface-to-surface matching techniques. Angle Orthod 89:590–596. https://doi.org/10.2319/081718-607.1

    Article  PubMed  Google Scholar 

  30. 30.

    Leonardi R, Muraglie S, Crimi S, Pirroni M, Musumeci G, Perrotta R (2018) Morphology of palatally displaced canines and adjacent teeth, a 3-D evaluation from cone-beam computed tomographic images. BMC Oral Health 18:156. https://doi.org/10.1186/s12903-018-0617-0

    Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Leonardi R, Muraglie S, Lo Giudice A, Aboulazm KS, Nucera R (2020) Evaluation of mandibular symmetry and morphology in adult patients with unilateral posterior crossbite: a CBCT study using a surface-to-surface matching technique. Eur J Orthod. https://doi.org/10.1093/ejo/cjz106

  32. 32.

    Lee SY, Choi DS, Jang I, Song GS, Cha BK (2017) The genial tubercle: A prospective novel landmark for the diagnosis of mandibular asymmetry. Korean J Orthod 47:50–58. https://doi.org/10.4041/kjod.2017.47.1.50

    Article  PubMed  Google Scholar 

  33. 33.

    Neiva MB, Soares AC, Lisboa Cde O, Vilella Ode V, Motta AT (2015) Evaluation of cephalometric landmark identification on CBCT multiplanar and 3D reconstructions. Angle Orthod 85:11–17. https://doi.org/10.2319/120413-891.1

    Article  PubMed  Google Scholar 

  34. 34.

    G. D (1940) Statistical methods for medical and biological students. Interscience Publications, New York

    Google Scholar 

  35. 35.

    Alarcon JA, Martin C, Palma JC (2000) Effect of unilateral posterior crossbite on the electromyographic activity of human masticatory muscles. Am J Orthod Dentofac Orthop 118:328–334. https://doi.org/10.1067/mod.2000.103252

    Article  Google Scholar 

  36. 36.

    Bresin A, Kiliaridis S, Strid KG (1999) Effect of masticatory function on the internal bone structure in the mandible of the growing rat. Eur J Oral Sci 107:35–44

    Article  Google Scholar 

  37. 37.

    Kiliaridis S, Mahboubi PH, Raadsheer MC, Katsaros C (2007) Ultrasonographic thickness of the masseter muscle in growing individuals with unilateral crossbite. Angle Orthod 77:607–611. https://doi.org/10.2319/101105-360

    Article  PubMed  Google Scholar 

  38. 38.

    Rodrigues L, Traina AA, Nakamai LF, Luz JG (2009) Effects of the unilateral removal and dissection of the masseter muscle on the facial growth of young rats. Braz Oral Res 23:89–95

    Article  Google Scholar 

  39. 39.

    Sarnat BG (1988) Craniofacial change and non-change after experimental surgery in young and adult animals. Angle Orthod 58:321–342. https://doi.org/10.1043/0003-3219(1988)058<0321:CCANAE>2.0.CO;2

    Article  PubMed  Google Scholar 

  40. 40.

    Tsanidis N, Antonarakis GS, Kiliaridis S (2016) Functional changes after early treatment of unilateral posterior cross-bite associated with mandibular shift: a systematic review. J Oral Rehabil 43:59–68. https://doi.org/10.1111/joor.12335

    Article  PubMed  Google Scholar 

  41. 41.

    Nerder PH, Bakke M, Solow B (1999) The functional shift of the mandible in unilateral posterior crossbite and the adaptation of the temporomandibular joints: a pilot study. Eur J Orthod 21:155–166

    Article  Google Scholar 

  42. 42.

    Bazina M, Cevidanes L, Ruellas A, Valiathan M, Quereshy F, Syed A, Wu R, Palomo JM (2018) Precision and reliability of Dolphin 3-dimensional voxel-based superimposition. Am J Orthod Dentofac Orthop 153:599–606. https://doi.org/10.1016/j.ajodo.2017.07.025

    Article  Google Scholar 

  43. 43.

    Solem RC, Ruellas A, Ricks-Oddie JL, Kelly K, Oberoi S, Lee J, Miller A, Cevidanes L (2016) Congenital and acquired mandibular asymmetry: mapping growth and remodeling in 3 dimensions. Am J Orthod Dentofac Orthop 150:238–251. https://doi.org/10.1016/j.ajodo.2016.02.015

    Article  Google Scholar 

  44. 44.

    Almukhtar A, Ju X, Khambay B, McDonald J, Ayoub A (2014) Comparison of the accuracy of voxel based registration and surface based registration for 3D assessment of surgical change following orthognathic surgery. PLoS One 9:e93402. https://doi.org/10.1371/journal.pone.0093402

    Article  PubMed  PubMed Central  Google Scholar 

  45. 45.

    Muraglie S, Musumeci G, Loreto C, Leonardi RM (2019) Role of ADAMTS4 and ADAMTS5 during early orthodontic tooth movement. J Biol Regul Homeost Agents 33:649–655

    PubMed  Google Scholar 

  46. 46.

    Bishara SE, Burkey PS, Kharouf JG (1994) Dental and facial asymmetries: a review. Angle Orthod 64:89–98. https://doi.org/10.1043/0003-3219(1994)064<0089:DAFAAR>2.0.CO;2

    Article  PubMed  Google Scholar 

  47. 47.

    Patcas R, Wiedemeier DB, Markic G, Beit P, Keller H (2017) Evidence of secular trend in mandibular pubertal growth. Eur J Orthod 39:680–685. https://doi.org/10.1093/ejo/cjx027

    Article  PubMed  Google Scholar 

  48. 48.

    Hagg U, Du X, Rabie AB (2002) Initial and late treatment effects of headgear-Herbst appliance with mandibular step-by-step advancement. Am J Orthod Dentofac Orthop 122:477–485. https://doi.org/10.1067/mod.2002.128218

    Article  Google Scholar 

Download references


This work has been performed with funds of the Department of General Surgery and Surgical-Medical Specialties, University of Catania, Catania, Italy.

Author information



Corresponding author

Correspondence to Rosalia Maria Leonardi.

Ethics declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Ethical approval was obtained from the Institutional Review Board of Indiana University-Purdue University (IRB protocol number: 1708606623).

Informed consent

Informed consent was obtained from all individual participants included in the study

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Leonardi, R.M., Aboulazm, K., Giudice, A.L. et al. Evaluation of mandibular changes after rapid maxillary expansion: a CBCT study in youngsters with unilateral posterior crossbite using a surface-to-surface matching technique. Clin Oral Invest (2020). https://doi.org/10.1007/s00784-020-03480-5

Download citation


  • RME
  • Crossbite
  • Facial asymmetry
  • CBCT
  • Orthodontics