Costa, Julia Garcia; Galindo, Thaís Magalhães; Mattos, Claudia Trindade; Cury-Saramago, Adriana de Alcantara

doi:10.1590/2177-6709.22.2.035-044.oar

RESUMO

OBJETIVO:

o objetivo da presente revisão sistemática foi avaliar a duração do período de contenção e a estabilidade do tratamento ortodôntico com expansão maxilar em pacientes em crescimento com mordida cruzada posterior.

MÉTODOS:

foram realizadas buscas estratégicas nas bases eletrônicas: Cochrane Library, Web of Science, PubMed e Scopus, até 15 de janeiro de 2016. Os critérios de inclusão foram: estudos clínicos controlados e randomizados, prospectivos ou retrospectivos, de pacientes em crescimento com mordida cruzada; tratados com aparelhos expansores maxilares, com fase de contenção pós-expansão e no mínimo seis meses de fase de pós-contenção. Os critérios de exclusão foram: mordida cruzada anterior, anomalias craniofaciais, cirurgia ou outro tratamento ortodôntico; relato de casos; artigos de opinião; teses; revisões de literatura e revisões sistemáticas. O risco de viés dos artigos selecionados foi avaliado a partir do Cochrane risk of bias tool para ensaios clínicos randomizados e Downs and Black checklist para ensaios clínicos não randomizados.

RESULTADOS:

a busca resultou em 156 títulos/resumos, sendo 44 textos examinados na íntegra. Foram selecionados 6 artigos para o acesso à qualidade metodológica. A duração do período de contenção ocorreu entre 4 semanas e 6 meses. Aparelhos fixos (aparelho em acrílico, Haas, Hyrax e quad-helix) ou removíveis (Hawley e Hawley com expansor) foram utilizados na fase de contenção.

CONCLUSÃO:

parece que seis meses de contenção com aparelhos fixos ou removíveis são suficientes para evitar a recidiva ou garantir mudanças mínimas em um curto período de acompanhamento pós-contenção.

Palavras-chave:
Mordida cruzada; Expansão Maxilar; Contenção.

[1] Contact address: Adriana de Alcantara Cury-Saramago Rua Mário Santos Braga, 30, 2º andar, sl. 214 - Campus do Valonguinho Centro - Niterói/RJ - Brazil - CEP: 24.020-140 E-mail: adrianacury@id.uff.br

PICOS	Description
Population	Growing subjects presenting posterior crossbite
Intervention	Treated with maxillary expansion
Comparison	Another maxillary expansion procedure, untreated crossbite subjects or untreated subjects without posterior crossbite
Outcomes	Duration of the retention period after maxillary expansion and its relation with posterior crossbite stability
Study design	Randomized controlled trials (RTCs) and controlled trials in human growing subjects

Database	Search strategy
Cochrane Library	“palatal expansion technic” or “maxillary expansion” in Title, Abstract, Keywords and “retention” or “retainer” or “stability” or “relapse” in Title, Abstract, Keywords and “crossbite” in Title, Abstract, Keywords not “case report” in Title, Abstract, Keywords (Word variations have been searched)
Web of Science (Database=SCI-EXPANDED, SSCI, A&HCI, CPCI-S, CPCI-SSH, BKCI-S, BKCI-SSH)	1) TS=(palatal expansion technic OR maxillary expansion OR maxillary disjunction OR palatal disjunction OR expansion appliance OR maxillary expander OR palatal expander OR maxillary expander) 2) TS=(retention* OR retainer* OR relapse* OR stability) 3) TS=(crossbite) 4) #1 AND #2 AND #3 5) TI=(case report OR case series OR adult*) 6) #4 AND NOT #5
PubMed	(palatal expansion technique[MeSH Terms]) OR “maxillary expansion”[Title/Abstract]) OR “maxillary disjunction”[Title/Abstract]) OR “palatal disjunction”[Title/Abstract]) AND “retention”[Title/Abstract]) OR orthodontic retainer[MeSH Terms]) OR “stability”[Title/Abstract]) OR “relapse”[Title/Abstract]) AND “crossbite”[Title/Abstract]) NOT “case report”[Title]) NOT “case series”[Title]) NOT adult[Title]
Scopus	TITLE-ABS-KEY(palatal expansion technique) OR TITLE-ABS-KEY(“maxillary expansion”) OR TITLE-ABS-KEY(“maxillary disjunction”) OR TITLE-ABS-KEY(“palatal disjunction”) AND TITLE-ABS-KEY(“retention”) OR TITLE-ABS-KEY(“retainers”) OR TITLE-ABS-KEY(“relapse”) OR TITLE-ABS-KEY(“post retention”) OR TITLE-ABS-KEY(“stability”) OR TITLE-ABS-KEY(“changes”) AND TITLE-ABS-KEY(crossbite) AND NOT TITLE-ABS-KEY(“case report”) AND NOT TITLE-ABS-KEY(“case series”) AND NOT TITLE-ABS-KEY(adult)

ALL CRITERIA	DESCRIPTION OF CRITERIA (with additional explanation as required, determined by consensus of raters)	POSSIBLE ANSWERS	Cozzani et al8	Godoy et al4	Mutinelli et al16	Primožič et al22
1	Is the hypothesis/aim/objective of the study clearly described? Must be explicit	0/1	1	1	1	1
2	Are the main outcomes to be measured clearly described in the Introduction or Methods sections?	0/1	1	1	1	1
3	Are the characteristics of the patients included in the study clearly described?	0/1	1	1	1	1
4	Are the interventions of interest clearly described?	0/1	1	1	1	1
5	Are the distributions of principal confounders in each group of subjects to be compared clearly described?	0/1/2	0	2	2	0
6	Are the main findings of the study clearly described?	0/1	1	1	1	1
7	Does the study provide estimates of the random variability in the data for the main outcomes?	0/1	1	1	1	1
8	Have all important adverse events that may be a consequence of the intervention been reported?	0/1	1	1	0	1
9	Have the characteristics of patients lost to follow-up been described?	0/1	0	0	0	0
10	Have actual probability values been reported (e.g. 0.035 rather than <0.05) for the main outcomes except where the probability value is less than 0.001?	0/1	0	1	1	0
11	Were the subjects asked to participate in the study representative of the entire population from which they were recruited?	0/0/1	0	1	0	0
12	Were those subjects who were prepared to participate representative of the entire population from which they were recruited?	0/0/1	0	1	0	0
13	Were the staff, places, and facilities where the patients were treated, representative of the treatment the majority of patients receive?	0/0/1	0	1	0	0
14	Was an attempt made to blind study subjects to the intervention they have received?	0/0/1	0	0	0	0
15	Was an attempt made to blind those measuring the main outcomes of the intervention?	0/0/1	0	1	0	0
16	If any of the results of the study were based on “data dredging”, was this made clear?	0/0/1	1	1	1	1
17	In trials and cohort studies, do the analyses adjust for different lengths of follow-up of patients, or in case control studies, is the time period between the intervention and outcome the same for cases and controls?	0/0/1	1	0	0	1
18	Were the statistical tests used to assess the main outcomes appropriate?	0/0/1	1	1	1	1
19	Was compliance with the intervention/s reliable?	0/0/1	1	0	1	1
20	Were the main outcome measures used accurate (valid and reliable)?	0/0/1	1	1	1	1
21	Were the patients in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited from the same population?	0/0/1	0	1	0	0
22	Were study subjects in different intervention groups (trials and cohort studies) or were the cases and controls (case-control studies) recruited over the same time?	0/0/1	1	1	0	0
23	Were study subjects randomized to intervention groups?	0/0/1	0	1	0	0
24	Was the randomized intervention assignment concealed from both patients and health care staff until recruitment was complete and irrevocable?	0/0/1	0	0	0	0
25	Was there adequate adjustment for confounding in the analyses from which the main findings were drawn?	0/0/1	0	0	1	1
26	Were losses of patients to follow-up taken into account?	0/0/1	0	1	0	1
27	Did the study have sufficient power to detect a clinically important effect where the probability value for a difference being due to chance <5%	1 - 5	0	4	4	0
TOTAL		Max. 32	13	25	18	14

Author/ Year	Sample description	Type of crossbite	Expander/ Activation time	Activation rate	Retainer appliance/ Retention time
^{Cozzani et al8 (2007}8. Cozzani M, Guiducci A, Mirenghi S, Mutinelli S, Siciliani G. Arch width changes with a rapid maxillary expansion appliance anchored to the primary teeth. Angle Orthod . 2007 Mar;77(2):296-302.)	» Group A (TG) = 31 (20 F/11 M) CB experimental 7.3 ± 1y » Group B (CG) = 30 (13 F/17 M) CB untreated 8.4y » Group C (CG) = 30 (13 F/17 M) CB untreated 10.8y	unilateral or bilateral posterior crossbite	Haas Group A (primary second molars and canines) mean 20 days (until permanent first molars correction)	RME once or twice/day 0.25 mm-0.5 mm/day	Haas at least 8m mean 1.1y
Lagravère et al17 (2010)	» Group TG= 20 (15F/5M) CB experimental 14.05±1.35y » Group CG= 21 (15F/6M) CB untreated 12.86± 1.19y	posterior crossbite	Hyrax (until posterior CB overcorrection)	RME twice/day 0.5 mm	Hyrax/ 6 months
Godoy et al4 (2011)	» Group QDH= 33 (26F/7M) CB-experimental 8.00±0.79y » Group EP= 33 (18F/15M) CB-experimental 7.82±0.85y » Group CG= 33 (14F/19M) CB-untreated 8.09±0.81y	unilateral posterior crossbite	QDH adjusted for buccal root torque mean 4.24±2.05m EP acrylic covering mean 6.12±3.25m (until CB correction) evaluated every 4 weeks	SME once a month QDH expanded 1 side to pass central fossa; and the other to the molar- band EP-0.25 mm/ week	Plate placed/ To be used 24 hours/ day for 3 months and for 3 more months just at night
Petrén et al21 (2011)	» Group QDH= 20 (11F/9M) CB-experimental 9.00±1.19y » Group EP= 15 (10F/5M) 5M noncompliance excluded CB-experimental 8.5± 1.02y » Group CG= 20 (9F/11M) NCB- 8.8± 0.5y	unilateral posterior crossbite	QDH adjusted for buccal root torque QDH and EP (until CB correction) CG untreated	SME QDH activated 10 mm, reactivated every 6 weeks/recemented EP 0.2 mm/week	QDH 6 months EP / 6 months 24 hours/day
Primožič et al22 (2013)	» Group TG= 30 (17F/13M) CB experimental - 5.3± 0.7 y » Group CG= 30 (17F/13)M NCB- 5.3± 0.7 y	unilateral posterior crossbite, mandibular lateral shift	Acrylic plate expander cemented/ 4 weeks	SSME 0.25 mm/ every 2 days	Acrylic plate expander inactive/ 4 weeks Acrylic removable plate/ 4 months
Mutinelli et al16 (2015)	» Group TG= 18 (10F/8M) CB experimental- 7.6±1.0y dental Class II » Group CG= 18 (10F/8M) CB-untreated- 13.1±1.6y dental Class II	unilateral or bilateral posterior crossbite	Haas/(primary second molars and canines) mean 28 days (until permanent first molars correction)	RME once or twice/ day 0.2 mm-0.4 mm/day	Haas/ 7 months 1.4y

Author/ Year	Measurements	Follow-up time	Overcorrection	Experimental group x Control group (P value)	Relapse measurements after follow-up	Crossbite corrected after follow-up	Conclusion
^{Cozzaniet al8 (2007}8. Cozzani M, Guiducci A, Mirenghi S, Mutinelli S, Siciliani G. Arch width changes with a rapid maxillary expansion appliance anchored to the primary teeth. Angle Orthod . 2007 Mar;77(2):296-302.)	» Maxillary arch width: » PFM- center of the fossa » PSM-center of the fossa » IC-cusp tip » DC	minimum 1 y after appliance removal 2.4 ± 1.7y	yes - primary teeth no - permanent first molar	PFM: ≤0.01 PSM: ≤0.01 IC: ≤0.05	PFM = 0.9% PSM = 6.0% IC = 5.5%	yes	Relapse: PFM < PSM Overexpand PSM PFM was stable for 2y 4m after treatment
Lagravere et al17 (2010)	» PC- center of pulp chamber in molars and tip of premolars buccal pulp horn » MBA-mesiobuccal root apex of molars » BA-buccal root apex of premolars » AIB-outer cortex of alveolar bone at the vertical level of the root apex » mm » CBCT	Before fixed bonding (12m) long-term post-relapse	yes	all groups P<.001	PC16-PC26 = 27% PC14-PC24 = 39% MBA16-MBA26= 28% BA14-BA24 = 18% AIB16-AIB26 = 51% AIB14-AIB24 = 20%	yes	aprox 4mm (70%) expansion - at T4 at molars Dental expansion> skeletal expansion Midpalatal suture separation on TG. No significant changes at the level of the pterigoid plates TG=CG
^{Godoy et al4 (2011}4. Godoy F, Godoy-Bezerra J, Rosenblatt A. Treatment of posterior crossbite comparing 2 appliances: a community-based trial. Am J Orthod Dentofacial Orthop . 2011 Jan;139(1):e45-52.)	Maxillary arch width: PSM-center of the fossa IC- cusp tip DC	6m after appliance removal	no	IMD: P<0.001 (QDH=EP; QDH≠ CG; EP≠ CG) ICD: P= 0.354	PSF QDH= 2.2% EP = 1.7% IC QDH = 0.3% EP = 0%	yes 9.1% of the each sample showed relapse	QDH=EP for correct posterior crossbite QDH> breakage EP> lost appliances QDH< treatment time Treatment may be performed in 1y for posterior CB correction and 6m for retention
^{Petrén et al21 (2011}21. Petrén S, Bjerklin K, Bondemark L. Stability of unilateral posterior crossbite correction in the mixed dentition: a randomized clinical trial with a 3-year follow-up. Am J Orthod Dentofacial Orthop . 2011 Jan;139(1):e73-81.)	Maxillary arch width: PSM-gingival margin (GM) PSM-mesiobuccal cusp tip (MCT) IC-gingival margin (GM) IC-buccal cusp tip (BCT) DC	QDH and EP group 4y after correction	no	IMD (MCT): P=NR (CG>QDH,EP) ICD (BCT): P=NR (CG>QDH)	PSM QDH = 1.6% EP = 5.6% IC (GM) QDH = 4.9% EP = 5.6% IC (BCT) QDH = 1.2% EP = 0.6%	yes	The long-term stability of crossbite correction in the mixed dentition is favorable. Results: QDH=EP
^{Primozic et al22 (2013}22. Primožič J, Richmond S, Kau CH, Zhurov A, Ovsenik M. Three-dimensional evaluation of early crossbite correction: a longitudinal study. Eur J Orthod. 2013 Feb;35(1):7-13.)	Palatal surface area (mm²) 3D digital DC	12 months later 18 months later 30 months later	yes	Surface(mm²): P= NR NS (TG=CG)	Palatal surface area (TG) = - 0.5%	26.7% of the TG showed relapse	Treatment of unilateral CB in the deciduous dentition also create conditions for normal occlusal and craniofacial development. Improves facial symmetry and increase palatal area and volume
^{Mutinelli et al16 (2015}16. Mutinelli S, Cozzani M. Rapid maxillary expansion in early-mixed dentition: effectiveness of increasing arch dimension with anchorage on deciduous teeth. Eur J Paediatr Dent. 2015 June;16(2):115-22.)	Maxillary arch width: PSM and IC (mm); 3D digital DC	In the permanent dentition 5.3 ± 0.8y	yes - primary teeth no - permanent first molar	IC P= 0.02 PSM P= 0.001	PSM = 1% IC = 5.1%	yes	In patients in canine Class II, early treatment of lateral CB with a modified Haas expander anchored to deciduous teeth is effective and presented stable results until the stage of permanent dentition