ORIGINAL ARTICLE

Bone-borne accelerated sutural

expansion: A microcomputed
tomography study in rabbits
Akram S. Alyessary,a Adrian U. J. Yap,b Siti A. Othman,c Norliza Ibrahim,d Mohammad T. Rahman,e
and Zamri Radzic
Kuala Lumpur, Malaysia, Kerbala, Iraq, and Singapore

Introduction: In this study, we evaluated the effect of bone-borne accelerated expansion protocols on sutural
separation and sutural bone modeling using a microcomputed tomography system. We also determined the
optimum instant sutural expansion possible without disruption of bone modeling. Methods: Sixteen New Zea-
land white rabbits, 20 to 24 weeks old, were randomly divided into 4 experimental groups. Modified hyrax ex-
panders were placed across their interfrontal sutures and secured with miniscrew implants located bilaterally
in the frontal bone. The hyrax appliances were activated as follows: group 1 (control), 0.5-mm per day
expansion for 12 days; group 2, 1-mm instant expansion followed by 0.5 mm per day for 10 days; group 3, 2.5-
mm instant expansion followed by 0.5 mm per day for 7 days, and group 4, 4-mm instant expansion followed
by 0.5 mm per day for 4 days. After 6 weeks of retention, sutural separation and sutural bone modeling were
assessed by microcomputed tomography and quantified. Statistical analysis was performed using Kruskal
Wallis and Mann-Whitney U tests and the Spearman rho correlation (P \0.05). Results: Median amounts of
sutural separation ranged from 2.84 to 4.41 mm for groups 1 and 4, respectively. Median bone volume fraction
ranged from 59.96% to 69.15% for groups 4 and 3, respectively. A significant correlation (r 5 0.970; P \0.01)
was observed between the amounts of instant expansion and sutural separation. Conclusions: Pending histo-
logic verifications, our findings suggest that the protocol involving 2.5 mm of instant expansion followed by
0.5 mm per day for 7 days is optimal for accelerated sutural expansion. When 4 mm of instant expansion was
used, the sutural bone volume fraction was decreased. (Am J Orthod Dentofacial Orthop 2018;154:260-9)

A
pproximately 8% to 18% of patients in the tooth-borne rapid maxillary expansion (RME) appli-
mixed dentition have transverse maxillary con- ances.1 Although tooth-borne RME appliances vary
strictions and are frequently managed with in their designs and rates of expansion,2,3 their
fundamental mechanisms remain the same.4 Rapid
a
Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, Uni- transverse forces are exerted on the maxillary teeth re-
versity of Malaya, Kuala Lumpur, Malaysia; Department of Orthodontics, College
sulting in interruption and separation of the midpalatal
of Dentistry, Kerbala University, Kerbala, Iraq.
b
Department of Dentistry, Ng Teng Fong General Hospital, National University sutures. The latter leads to extensive cellular activity in
Health System, Singapore; Department of Restorative Dentistry, Faculty of the sutures and encourages bone remodeling.5 As
Dentistry, University of Malaya, Kuala Lumpur, Malaysia.
c tooth-borne RME appliances transmit expansion forces
Department of Paediatric Dentistry and Orthodontics, Faculty of Dentistry, Uni-
versity of Malaya, Kuala Lumpur, Malaysia. through the teeth, dental and alveolar bone bending
d
Unit of Oral and Maxillofacial Imaging, Department of Oral and Maxillofacial also occurs during correction of the skeletal dishar-
Clinical Sciences, Faculty of Dentistry, University of Malaya, Kuala Lumpur,
monies.6 These movements take up the major fraction
Malaysia.
e
Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia. of total appliance activation, reducing the amount of
All authors have completed and submitted the ICMJE Form for Disclosure of Po- true skeletal expansion.7,8
tential Conflicts of Interest, and none were reported.
Recently, mini-implant assisted bone-borne RME ap-
Supported by High Impact Research MoE Grant UM.C/625/1/HIR/MOHE/DENT/
21 from the Ministry of Education Malaysia and Postgraduate Research Grant pliances that apply lateral forces directly to the midpala-
(PG295-2016A) from the University of Malaya. tal sutures were introduced.4,9,10 These appliances
Address correspondence to: Zamri Radzi, Department of Paediatric Dentistry and
produce greater orthopedic effects and fewer
Orthodontics, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur,
Malaysia; e-mail, zamrir@um.edu.my. dentoalveolar side effects compared with tooth-borne
Submitted, February 2017; revised, October 2017; accepted, November 2017. ones.11 Furthermore, they are well tolerated and easier
0889-5406/$36.00
to use than traditional tooth-borne expanders.12 The ef-
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.11.031 ficacy of bone-borne RME is affected by several factors

260
Alyessary et al
including the rate of distraction or activation. Clinical
activation protocols for tooth-borne expanders may
not apply to bone-borne ones. Since there is currently
no consensus on conventions for bone-borne expanders,
expansion protocols for these appliances warrant inves-
tigation.13 Koudstaal et al14 stated that when distraction
is performed too fast for tooth-borne expanders,
collagen fibers lose contact, and no ingrowth of new
bone occurs, resulting in nonunion or malunion of the
separated sutures. Conversely, if the distraction is too
slow, premature bone consolidation can occur, and the
required expansion cannot be achieved. The quality
and quantity of bone formation therefore depend,
partially, on the rate of sutural expansion. Although a
higher expansion rate has been associated with greater
sutural separation, the exact nature of this association
and the maximum instant expansion possible without
disruption of suture bone modeling remains uncertain.14
Several approaches to examining sutural bone
modeling have been taken.15-17 Microcomputed
tomography (micro-CT) is a nondestructive analytical
method that does not require arduous specimen
preparations and specific skills in microscopy. With
advances in micro-CT technology, higher resolution im-
ages with reduced metal artifacts can now be achieved.
They are particularly useful for assessing the properties
of spongy or trabecular bone, including bone density,
trabecular bone thickness, and connectivity.18-20 We
evaluated the effect of bone-borne accelerated expan-
sion protocols on sutural separation and sutural bone
modeling using micro-CT. We also determined the opti-
mum instant sutural expansion possible without disrup-
tion of bone modeling. The null hypotheses were as
follows: there is (1) no difference in sutural separation
and bone modeling between dissimilar expansion proto-
cols, and (2) no optimum instant sutural expansion
beyond which sutural bone modeling will be disrupted.
MATERIAL AND METHODS
The interfrontal suture of rabbits had been proposed
as an animal model for palatal expansion and was
selected for our study.17 These sutures were found to
act analogously to the midpalatal sutures. In addition,
the haversian systems of rabbits are similar to those of
humans, allowing for some extrapolation of results to
clinical applications.16,21 Furthermore, rabbits are
adequately small for use with micro-CT, permitting
whole-body insertion into the micro-CT chamber for
repeated measurements. The frontal areas were also suf-
ficiently wide for the fixation of the palatal expander and
4 miniscrew implants. Adult rabbits (age, 5-6 months;
weight, 3-4 kg) were chosen to reduce confounding
American Journal of Orthodontics and Dentofacial Orthopedics
261
factors from continuous growth or bone remodeling.22
Male rabbits were selected to reduce the effects of hor-
monal variations and to capitalize on their wider frontal
bone.
The study was approved by the Faculty of Medicine
Institutional Animal Care and Use Committee, University
of Malaya (2015-16/006/DENTAL/R/ASH), and all ani-
mal work was performed according to the standards
specified by the institutional animal care and use com-
mittee of the University of Malaya, which is accredited
by the Association for Assessment and Accreditation of
Laboratory Animal Care International. Sixteen New Zea-
land white rabbits, 20 to 24 weeks old, were selected for
the study. Sample size calculation was based on the
resource equation method (E).23 “E” can be measured
by the following formula: E 5 total number of
animals total number of groups. According to this
method, a sample size with E between 10 and 20 can
be considered as adequate (E was 12 in this study).
The adult male rabbits (approximately 3.0-4.0 kg) were
procured from a licensed farm by the animal experi-
mental unit of the. University of Malaya. Upon their
arrival, the rabbits were examined, weighed, and
observed twice daily for 2 weeks until their acclimatiza-
tion. Environmental conditions were maintained as fol-
lows: pathogen-free environment with a temperature of
22 C 6 3 C; humidity of 55% 6 10%; and a 12:12 hour
light:dark cycle with lights on at 0700 and off at
1900. The animals were housed singly in cages (Techni-
plast, Buguggiate, Italy) with paper liners. They
received maintenance food (2023 diet; Altromin Inter-
national, Martinsried, Germany) and reverse-osmosis
treated water. They were cared for according to the
guidelines of the Animal Research Reporting of In Vivo
Experiments. Preoperative intramuscular ketamine,
30 mg per kilogram (Troy Laboratories, Smithfield,
Australia), and 3 mg per kilogram of xylozine (Troy Lab-
oratories) were administered. The distraction sites were
then anesthetized using marcaine (2 mg/kg; Abbott Lab-
oratories, Chicago, Ill) with 1:200,000 epinephrine. Gen-
eral anesthesia was subsequently accomplished with 1%
to 3% isoflurane in a 2:1 oxygen/nitrous oxide mixture
administered through special facemasks.
Modified expanders were fabricated by laser welding
of 4 stainless steel U loops (0.9 mm) to hyrax expanders
(Leone, Firenze, Italy). The mucosa and periosteum at
the distraction sites between the anterior and posterior
limits of the orbital rims were reflected to expose the in-
terfrontal sutures and frontal bones. The modified ex-
panders were positioned across the interfrontal sutures
and secured with 4 miniscrew implants (Dentos, Daegu,
Korea), 5.0 mm long and 1.7 mm in diameter, using a
manual driver (Fig 1). The surgical flaps were
August 2018  Vol 154  Issue 2
262
Fig 1. The modified hyrax expander secured with mini-
screw implants. MSS, Interfrontal suture; UL, U loop
made from 0.9-mm stainless steel wire; MSIs, miniscrew
implants (5.0 mm length, 1.7 mm diameter); MHE, modi-
fied hyrax expander.
subsequently closed, and the rabbits were given intra-
muscular kombitrim (1 ml/10 kg) (sulfamethoxazole
200 mg and trimethoprim 40 mg) (Kela Laboratoria,
Hoogstraten, Belgium) postoperatively to prevent infec-
tion, and meloxicam (0.2 mg/kg; Poly Car Labs, Gujarat,
India) to minimize discomfort.
The rabbits with their bone-borne expanders were
randomly divided into 4 groups, and the hyrax appli-
ances were activated as follows: group 1 (control),
0.5 mm per day expansion for 12 days24,25; group 2,
1 mm instant expansion followed by 0.5 mm per
day for 10 days26,27; group 3, 2.5 mm instant
expansion followed by 0.5 mm per day for 7 days;
and group 4, 4 mm instant expansion followed by
0.5 mm per day for 4 days. Thus, a total expansion
of the hyrax appliances of 6 mm was applied in all
groups. After active expansion, the screws on the
hyrax appliances were fixed with light-cured acrylic
and left passive for consolidation. After 6 weeks of
retention, sutural separation and bone modeling
were assessed by micro-CT.
Before micro-CT imaging, the rabbits were again
anesthetized with ketamine and xylazine. Posttreat-
ment scans of the distraction sites were obtained using
high resolution in-vivo x-ray micro-CT imaging (Xtre-
meCT; Scanco Medical, Bassersdorf, Switzerland). Serial
tomographic images were acquired transverse to the
August 2018  Vol 154  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Alyessary et al
interfrontal sutures at 60 kV(p) and 900 mA. One thou-
sand projections were acquired per rotation with an
integration time of 300 ms and a voxel size of 41 mm.
An aggregate of 160 slices located between the ante-
rior and posterior miniscrew implants was selected. A re-
gion of interest was selected 3 mm from the midline (left
and right) and applied to all samples (Fig 2, A). Three-
dimensional (3D) images of the region of interest were
automatically reconstructed from these 160 slices (Fig
2, C) using the Scanco software (micro-CT evaluation
program, version 6.5.3). A Gaussian filter with a sigma
value of 0.9 and support value of 1 was used to reduce
image noise. The threshold value was set between 130
(lower value) and 1000 (upper value) units to discrimi-
nate between the less-dense newly formed bone and
the denser old bone28 based on a previous similar
study29 and data from our pilot study. Bone-volume
fraction (BV/TV) at the suture was then measured using
Scanco software.
After segmentation of bone tissues using the above
threshold values, a 3D color map of the suture tissue sep-
aration was generated. Separation maps of the suture
tissue indicate maximum separation values with blue
to red colors specifying increasing degrees of tissue sep-
aration (Fig 2, B).30,31
To calculate the sutural space volume, micro-CT im-
ages were exported into medical imaging software
(Mimics, version 17.0; Materialise, Leuven, Belgium).
For consistency, the same threshold values (224-
1249) were used for all specimens to separate soft tis-
sue from bone tissue. As a result, the soft tissue was
highlighted in yellow using the so-called masks. The
mask was cropped to select the region of interest and
used for all specimens. Region growing (computer-as-
sisted tissue separation) and manual tissue deletion
(using the multiple slice editing tool) were used to
isolate the region of interest.32 The software then
calculated the sutural soft tissue volume (sutural space
volume) by means of voxel addition and reconstructed
a 3D image (Fig 3).
The amount of sutural separation was established
with the RadiAnt DICOM viewer (version 3.4.1; Medi-
xant, Poznan, Poland). The most anterior and posterior
slices for the region of interest were first ascertained to
locate the bony outline of the sutures. Sutural separation
was then calculated with the distance measurement tool
(Fig 4) at the point equidistant between the outer surface
and the inner surface of the frontal bone and using an
average of 2 separate readings. Intraexaminer reliability
for mapping the region of interest sutural space volume
and measuring suture separation was assessed by
repeating the procedures blindly after 2 weeks. Reli-
ability was evaluated using the Cronbach alpha test.
Alyessary et al 263

Fig 2. A, Two-dimensional images showing the regions of interest (yellow boxes) at the interfrontal su-
ture 6 weeks postretention; B, 3D maps showing the degree of suture tissue separation, increasing
from blue to red (blue indicates no tissue separation; red indicates maximum separation); C, 3D seg-
mentations showing the sutural space. The white dotted line represents the midline of the suture. The
region of interest was 3 mm on either side of the dotted line.

Statistical analysis test. Because the data were not normally distributed,
All data were analyzed with the Statistical Package nonparametric Kruskal Wallis and Mann-Whitney U tests
for Social Sciences software (verion 20.0; IBM, Armonk, (P \0.05) were used to determine significant differences
NY). Normality testing was done using the Shapiro-Wilk in sutural separation, BV/TV, sutural space volume, and

American Journal of Orthodontics and Dentofacial Orthopedics August 2018  Vol 154  Issue 2
264 Alyessary et al

Fig 3. Overview of the axial, coronal, and sagittal micro-CT slices with the highlighted segmented tis-
sue (yellow indicates sutural space volume) and the 3D reconstruction of the segmented tissue.

Fig 4. Method of measuring sutural separation at the interfrontal suture of rabbits (separation equidis-
tant between outer and inner surfaces): A, preexpansion; B, postexpansion. OS, Outer surface (toward
the skin); IS, inner surface (toward the nasal floor); 4.2 mm, the amount of sutural separation.

sutural tissue separation between treatment groups.
Spearman rho correlations (P \0.05) were also per-
formed to establish the associations between the vari-
ables.
RESULTS
During the experiment, no peculiarity in weight
gained (range, 0.72-0.97 kg) was observed in the rabbits
in the 4 groups. There were also no signs of distraction
site infection or animal discomfort from the customized
distractors. The overall success rate of the miniscrew im-
plants was 98.44% (63 of 64). Only 1 miniscrew implant
was displaced upon direct hyrax activation, caused
mainly by operator issues. The dislodged miniscrew
implant was promptly replaced with a new one buccal
to the original site. Reliability testing showed no

August 2018  Vol 154  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Alyessary et al 265

Table. Median sutural separation and bone parameters with interquartile ranges (IQR) for the groups
Variable Group 1 (control) Group 2 Group 3 Group 4 P value
Sutural separation (mm)
ASS
Median 2.99 3.12 3.77 4.55 0.004*
IQR 2.85-3.04 2.97-3.20 3.71-3.82 4.42-4.63
PSS
Median 2.71 2.78 3.61 4.27 0.005*
IQR 2.65-2.78 2.70-2.87 3.53-3.64 4.18-4.35
Average
Median 2.84 2.92 3.69 4.41 0.003*
IQR 2.80-2.87 2.88-3.02 3.62-3.73 4.30-4.49
BV/TV (%)
Median 66.85 67.14 69.15 59.96 0.005*
IQR 66.08-67.66 66.63-67.46 68.54-69.67 58.88-60.45
Sutural space volume (mm3)
Median 12.01 10.80 7.57 21.01 0.004*
IQR 11.40-12.95 9.70-12.08 6.86-8.29 20.40-21.87
Sutural tissue separation (mm)
Median 0.76 0.73 0.65 1.74 0.004*
IQR 0.73-0.79 0.73-0.74 0.61-0.68 1.71-1.80

BV/TV, Bone volume fraction; ASS, anterior sutural separation; PSS, posterior sutural separation.
*Statistically significant differences, results of Kruskal-Wallis test (P \0.05).

4.41 mm for groups 1 to 4, respectively (Table). Paired

Fig 5. Median sutural separation (mm) for the various
groups at 6 weeks postretention. As instant expansion in-
creases, the amount of sutural separation increases
accordingly. Maximum sutural separation was observed
in group 4 (4.41 mm), and the minimum in group 1
(2.84 mm). *Significant differences at P \0.05.
significant difference in measurements between the 2
assessment periods (a 5 0.946).
Median values were 2.99, 3.12, 3.77, and 4.55 mm
for anterior sutural separation, and 2.71, 2.78, 3.61,
and 4.27 mm for posterior sutural separation in groups
1 to 4, respectively (Table). Median values for average
sutural separations were 2.84, 2.92, 3.69, and
comparisons showed statistically significant differences
in sutural separation between all groups. All experi-
mental groups had significantly higher sutural separa-
tions than did the control group (group 1). Sutural
separations for group 2 (2.82%), group 3 (29.93%),
and group 4 (55.28%) were higher than those for group
1. Sutural separation for group 4 was significantly higher
than for groups 2 and 3, whereas group 3 had a signif-
icantly higher separation than did group 2 (Fig 5). The
Spearman correlation test showed a strong, positive,
and significant correlation (r 5 0.970; P \0.01) be-
tween sutural separation and instant expansion.
Median BV/TV, sutural space volume, and sutural tis-
sue separation after 6 weeks of retention are also shown
in the Table. Group 4 had a significantly lower BV/TV
than all other groups. Group 3 had a significant higher
BV/TV than groups 1 and 2 (Fig 6). The amount of su-
tural space volume in group 4 was significantly higher
compared with the other groups, whereas in group 3,
it was significantly lower than all other groups (Fig 7).
Similarly, the amount of sutural tissue separation in
group 4 was significantly higher than in all other groups;
in group 3, it was significantly lower compared with the
other groups.
The relationship between BV/TV and sutural separa-
tion was linear up to 3.69 mm (group 3). After this crit-
ical point, the relationship was inverted, and BV/TV was
decreased. In contrast, the Spearman correlation test
showed a strong, negative, and significant correlation

American Journal of Orthodontics and Dentofacial Orthopedics August 2018  Vol 154  Issue 2
266
Fig 6. Median BV/TV changes (%) at 6 weeks postreten-
tion for the groups. Maximum BV/TV was observed in
group 3 and minimum in group 4. *Significant differences
at P \0.05.
Fig 7. Median sutural space volume (mm3) at 6 weeks
postretention for the groups with the Mimics software.
Maximum sutural space volume was observed in group
4 and minimum in group 3. *Significant differences at
P \0.05.
(r 5 –0.932; P\0.01) between BV/TV and sutural space
volume.
DISCUSSION
The effect of bone-borne accelerated expansion pro-
tocols on sutural separation and sutural bone modeling
was investigated in this study. Since significant differ-
ences in sutural separation and BV/TV were observed
between the various expansion protocols, the null
August 2018  Vol 154  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Alyessary et al
hypotheses were rejected. Anchorage for the modified
expanders was achieved with miniscrew implants. The
success rate of the miniscrew implants (98.44%) was
relatively higher than that reported by Liu et al16
(88%) in a similar rabbit model. The incongruity may
be attributed to the use of more and longer miniscrew
implants in our study (5 mm vs 3 mm) and the strength
of the laser welded joint between the U loops and hyrax
expanders. Moreover, Liu et al used nickel-titanium
open-coil springs that provided limited control over
the direction and amount of forces on the miniscrew im-
plants. Our success rate was similar to that of Carrillo
et al,33 who reported 99% success when miniscrew im-
plants were used for orthodontic anchorage in beagle
dogs. Garfinkle et al34 found that loaded miniscrew im-
plants have higher success rates than unloaded ones, and
proposed that applied forces augment initial mechanical
retention and stimulate osseous adaptation. This was
corroborated by the high success rate of the loaded min-
iscrew implants in our study.
For all groups, the amount of sutural separation was
slightly greater anteriorly than posteriorly. This observa-
tion was consistent with those reported by Liu et al.16
The difference between the anterior and posterior seg-
ments was, however, statistically insignificant. The
pattern of differential sutural expansion has also been
reported in humans since the posterior part of the mid-
palatal suture articulates with more bones than the ante-
rior portion.24,35 The frontal bone in rabbits articulates
with the nasal bone anteriorly and the parietal bone
posteriorly. Because the parietal bone connects to
more skeletal structures than does the nasal bone,
more skeletal resistance and less sutural expansion are
expected posteriorly.
In this study, the expanded suture was irregular,
with the inner surface (toward the brain) less enlarged
than the outer surface (toward the mucosa). These ir-
regularities can be attributed to differential bone
modeling between the inner and outer surfaces of
the sutures. Generally during surgical incisions, the
periosteum is detached from the outer surface of the
interfrontal suture and adjacent bone. This could
lead to disruption of the periosteal microcirculation
to the suture and osteogenic potential of the perios-
teum. As a result, periosteal blood flow reduction
and subsequently decreased bone modeling occur. In
contrast, the inner surface of the suture and the adja-
cent bone are still covered by the periosteum, result-
ing in greater bone modeling.36,37 Sutural separation
escalated with increasing instant expansion. A higher
instant sutural expansion might have loosened the
interfrontal suture, reducing bony resistance and
allowing for more sutural separation.
Alyessary et al
In distraction osteogenesis, an increased amount of
new bone formation appeared to result from rapid
recruitment and activation of bone-forming cells and
the increased surface area available for matrix deposition
and mineralization.30 Although the BV/TV responded to
increasing instant expansion, a critical point was reached
with an instant expansion of 2.5 mm. The BV/TV
conversely decreased by about 13.29% when the instant
expansion increased to 4 mm (Fig 6). As the instant
expansion increases, the expansion forces will escalate
correspondingly. The force exerted at 4 mm of instant
expansion is probably too extreme, leading to the
decreased BV/TV observed. DNA synthesis of fibroblasts
and osteoblasts plateaus after a certain expansion force
magnitude. Excessive forces inhibit anabolic activities
because of tissue rupture and bleeding38 and can result
in cell death.39 These events might explain the negative
correlation between BV/TV and the amount of sutural
space volume observed in our study.
The rate of distraction (incremental lengthening per
day) has also been identified as a significant factor in
new sutural bone formation and consolidation.26,40,41
Higher rates of distraction also enhance bone
modeling but only to a critical measure. Ilizarov et al40
reported that a rate of 60 times per day resulted in signif-
icantly greater new bone formation compared with
lower rates of 1 to 4 times per day. The rate of distraction
during the active phase was fixed at 2 turns (0.5 mm) per
day in our study. The collective effect of increased
instant suture expansion and rate of distraction warrants
further investigation. By the same token, the influence
of retention times and degree of relapse associated
with various expansion protocols also needs to be clari-
fied.
We used micro-CT for quantitative analysis of sutural
separation and sutural bone modeling. A careful selec-
tion of threshold values in micro-CT analysis is essential
for accurate determination of structural and trabecular
bone properties.42 This value is largely influenced by
the type of scanning machine, scanning resolution,
type of sample, and anatomic region.42-44 The lower
threshold value that we used was similar to that
advocated by Lu and Rabie29 using the same scanning
machine and an animal model for examining bone grafts
in destructed rabbit mandibles. In a recent micro-CT
study by Pulver et al17 that closely resembled our study,
lower threshold values of 0 to 72 units were used to
identify new bone. These values may not apply to our
study due to differences in scanning machines, resolu-
tions, and image analysis softwares. Freeman et al28
and Nakahara et al45 used lower threshold values of
225 and 220 units, respectively, to represent new bone
in their animal models with the same scanning machine
American Journal of Orthodontics and Dentofacial Orthopedics
267
and software. The variance in the lower threshold values
may, however, be attributed to the use of different ani-
mal models (rats) and anatomic regions (femur and cal-
varial bones vs frontal suture). Furthermore, the lower
threshold value used to represent the new sutural bone
is affected by the thickness or density of other materials
surrounding the suture (eg. miniscrew implant). As a
result, the same object or material scanned with little
or no surrounding material will have a higher density
in the computed tomography image than when sur-
rounded by a thick layer of a material.46 For this reason,
a histomorphometric analysis was planned as an exten-
sion of this study.
This study, however, yielded useful information for
the refinement of surgically assisted RME procedures.
Greater initial expansion may be feasible at the time of
surgery under anesthesia. This could be coupled with a
shorter period of gradual expansion after the surgery,
reducing the total treatment time. Collectively, this study
and future studies will facilitate the optimization of clin-
ical protocols for bone-borne accelerated maxillary
expansion.
CONCLUSIONS
Within the limits of this study, sutural separation
correlated with instant expansion. The expansion proto-
col involving 2.5 mm of instant expansion followed by
0.5 mm of expansion per day for 7 days resulted in the
highest BV/TV and may be optimal for bone-borne
accelerated sutural expansion. When 4 mm of instant
expansion was used, the sutural bone volume fraction
was decreased. Future studies on the collective effects
of instant expansion, the rate of active expansion, and
retention duration on osteogenesis are necessary before
a conclusive protocol for miniscrew implant-assisted
bone-borne accelerated maxillary expansion can be
derived.
ACKNOWLEDGMENT
We thank Karuthan Chinna from the Department of
Social and Preventive Medicine, Faculty of Medicine,
at the University of Malaya for the statistical analysis
of the data.
REFERENCES
1. Da Silva Filho OG, Boas MC, Capelozza Filho L. Rapid maxillary
expansion in the primary and mixed dentitions: a cephalometric
evaluation. Am J Orthod Dentofacial Orthop 1991;100:171-9.
2. Bench RW. The quad helix appliance. Semin Orthod 1998;4:231-7.
3. Mundstock KS, Barreto G, Meloti AF, Ara
ujo MA, dos Santos-
Pinto A, Raveli DB. Rapid maxillary expansion with the hyrax appli-
ance: an occlusal radiographic evaluation study. World J Orthod
2007;8:277-84.
August 2018  Vol 154  Issue 2
268
4. Proffit WR, Fields HW Jr, Sarver DM. Contemporary orthodontics.
5th ed. St Louis: Elsevier; 2014.
5. Starnbach H, Bayne D, Cleall J, Subtelny JD. Facioskeletal and
dental changes resulting from rapid maxillary expansion. Angle
Orthod 1966;36:152-64.
6. Graber LW, Vanarsdall RL Jr, Vig KW. Orthodontics: current prin-
ciples and techniques. 5th ed. Philadelphia: Elsevier; 2011.
7. Garrett BJ, Caruso JM, Rungcharassaeng K, Farrage JR, Kim JS,
Taylor GD. Skeletal effects to the maxilla after rapid maxillary
expansion assessed with cone-beam computed tomography. Am
J Orthod Dentofacial Orthop 2008;134:8-9.
8. Basciftci F, Karaman A. Effects of a modified acrylic bonded rapid
maxillary expansion appliance and vertical chin cap on dentofacial
structures. Angle Orthod 2002;72:61-71.
9. Lagravere MO, Carey J, Heo G, Toogood RW, Major PW. Trans-
verse, vertical, and anteroposterior changes from bone-anchored
maxillary expansion vs traditional rapid maxillary expansion: a
randomized clinical trial. Am J Orthod Dentofacial Orthop 2010;
137:304.e1-12.
10. Carlson C, Sung J, McComb RW, Machado AW, Moon W. Microim-
plant-assisted rapid palatal expansion appliance to orthopedically
correct transverse maxillary deficiency in an adult. Am J Orthod
Dentofacial Orthop 2016;149:716-28.
11. Lin L, Ahn HW, Kim SJ, Moon SC, Kim SH, Nelson G. Tooth-borne
vs bone-borne rapid maxillary expanders in late adolescence.
Angle Orthod 2015;85:253-62.
12. Garreau E, Bouscaillou J, Rattier S, Ferri J, Raoul G. Bone-borne
distractor versus tooth-borne distractor for orthodontic distraction
after surgical maxillary expansion: the patient's point of view. Int
Orthod 2016;14:214-32.
13. Carvalho Trojan L, Andr
es Gonz
alez-Torres L, Claudia Moreira
Melo A, Barbosa de Las Casas E. Stresses and strains analysis using
different palatal expander appliances in upper jaw and midpalatal
suture. Artif Organs 2017;41:E41-51.
14. Koudstaal MJ, Poort LJ, van der Wal KG, Wolvius EB, Prahl-
Andersen B, Schulten AJ. Surgically assisted rapid maxillary expan-
sion (SARME): a review of the literature. Int J Oral Maxillofac Surg
2005;34:709-14.
15. Liu SS, Kyung HM, Buschang PH. Continuous forces are more
effective than intermittent forces in expanding sutures. Eur J Or-
thod 2010;32:371-80.
16. Liu SS, Opperman LA, Kyung HM, Buschang PH. Is there an
optimal force level for sutural expansion? Am J Orthod Dentofacial
Orthop 2011;139:446-55.
17. Pulver RJ, Campbell PM, Opperman LA, Buschang PH. Miniscrew-
assisted slow expansion of mature rabbit sutures. Am J Orthod
Dentofacial Orthop 2016;150:303-12.
18. Ito M. Assessment of bone quality using micro-computed tomog-
raphy (micro-CT) and synchrotron micro-CT. J Bone Miner Metab
2005;23(Suppl):115-21.
19. Mulder L, van Groningen LB, Potgieser YA, Koolstra JH, van
Eijden TM. Regional differences in architecture and mineralization
of developing mandibular bone. Anat Rec A Discov Mol Cell Evol
Biol 2006;288:954-61.
20. Numata Y, Sakae T, Nakada H, Suwa T, LeGeros RZ, Okazaki Y,
et al. Micro-CT analysis of rabbit cancellous bone around implants.
J Hard Tissue Biol 2007;16:91-3.
21. Nunamaker DM. Experimental models of fracture repair. Clin Or-
thop Relat Res 1998;(355 Suppl):S56-65.
22. Suckow MA, Schroeder V. The laboratory rabbit. Boca Raton, Fla:
Taylor & Francis; 1997.
23. Festing MF. Design and statistical methods in studies using animal
models of development. ILAR J 2006;47:5-14.
August 2018  Vol 154  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Alyessary et al
24. Akin M, Akgul YE, Ileri Z, Basciftci FA. Three-dimensional evalua-
tion of hybrid expander appliances: a pilot study. Angle Orthod
2016;86:81-6.
25. Zimring JF, Isaacson RJ. Forces produced by rapid maxillary
expansion. 3. Forces present during retention. Angle Orthod
1965;35:178-86.
26. Paley D. Current techniques of limb lengthening. J Pediatr Orthop
1988;8:73-92.
27. Welch RD, Birch JG, Makarov MR, Samchukov ML. Histomorph-
ometry of distraction osteogenesis in a caprine tibial lengthening
model. J Bone Miner Res 1998;18:1-9.
28. Freeman TA, Patel P, Parvizi J, Antoci V Jr, Shapiro IM. Micro-CT
analysis with multiple thresholds allows detection of bone forma-
tion and resorption during ultrasound-treated fracture healing. J
Orthop Res 2009;27:673-9.
29. Lu M, Rabie A. Microarchitecture of rabbit mandibular defects
grafted with intramembranous or endochondral bone shown by
micro-computed tomography. Br J Oral Maxillofac Surg 2003;
41:385-91.
30. Hildebrand T, R€ uegsegger P. A new method for the model-
independent assessment of thickness in three-dimensional images.
J Microsc 1997;185:67-75.
31. Palmer AW, Guldberg RE, Levenston ME. Analysis of cartilage ma-
trix fixed charge density and three-dimensional morphology via
contrast-enhanced microcomputed tomography. Proc Natl Acad
Sci U S A 2006;103:19255-60.
32. Regensburg NI, Kok PH, Zonneveld FW, Baldeschi L, Saeed P,
Wiersinga WM, et al. A new and validated CT-based method for
the calculation of orbital soft tissue volumes. Invest Ophthalmol
Vis Sci 2008;49:1758-62.
33. Carrillo R, Rossouw PE, Franco PF, Opperman LA, Buschang PH.
Intrusion of multiradicular teeth and related root resorption with
mini-screw implant anchorage: a radiographic evaluation. Am J
Orthod Dentofacial Orthop 2007;132:647-55.
34. Garfinkle JS, Cunningham LL Jr, Beeman CS, Kluemper GT,
Hicks EP, Kim MO. Evaluation of orthodontic mini-implant
anchorage in premolar extraction therapy in adolescents. Am J Or-
thod Dentofacial Orthop 2008;133:642-53.
35. Wertz RA. Skeletal and dental changes accompanying rapid mid-
palatal suture opening. Am J Orthod 1970;58:41-66.
36. Stoetzer M, Felgentr€ager D, Kampmann A, Schumann P, R€ ucker M,
Gellrich NC, et al. Effects of a new piezoelectric device on perios-
teal microcirculation after subperiosteal preparation. Microvasc
Res 2014;94:114-8.
37. Squier CA, Ghoneim S, Kremenak CR. Ultrastructure of the perios-
teum from membrane bone. J Anat 1990;171:233-9.
38. M€orndal O. The importance of force magnitude on the initial
response to mechanical stimulation of osteogenic and soft tissue.
Eur J Orthod 1987;9:288-94.
39. Zahrowski JJ, Turley PK. Force magnitude effects upon osteopro-
genitor cells during premaxillary expansion in rats. Angle Orthod
1992;62:197-202.
40. Ilizarov GA, Lediaev VI, Shitin VP. The course of compact bone
reparative regeneration in distraction osteosynthesis under
different conditions of bone fragment fixation (experimental
study). Eksp Khir Anesteziol 1969;14:3-12.
41. Leong JC, Ma RY, Clark JA, Cornish LS, Yau AC. Viscoelastic
behavior of tissue in leg lengthening by distraction. Clin Orthop
Relat Res 1979;139:102-9.
42. Hara T, Tanck E, Homminga J, Huiskes R. The influence of micro-
computed tomography threshold variations on the assessment of
structural and mechanical trabecular bone properties. Bone
2002;31:107-9.
Alyessary et al
43. Ding M, Odgaard A, Hvid I. Accuracy of cancellous bone volume frac-
tion measured by micro-CT scanning. J Biomech 1999;32:323-6.
44. Campbell GM, Sophocleous A. Quantitative analysis of bone and
soft tissue by micro-computed tomography: applications to
ex vivo and in vivo studies. Bonekey Rep 2014;3:564.
45. Nakahara K, Haga-Tsujimura M, Sawada K, Mottini M,
Schaller B, Saulacic N. Periosteal distraction osteogenesis
American Journal of Orthodontics and Dentofacial Orthopedics
269
versus immediate periosteal elevation in a rat model: Histo-
logical and micro-CT analysis. J Craniomaxillofac Surg
2017;45:620-7.
46. Bouxsein ML, Boyd SK, Christiansen BA, Guldberg RE, Jepsen KJ,
M€uller R. Guidelines for assessment of bone microstructure in ro-
dents using micro–computed tomography. J Bone Miner Res
2010;25:1468-86.
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