Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"

Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"

Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
Knowledge is treasure of a wise man. The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."

Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help ones reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsNo manuscriptsNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Important Notice

Year : 2011 | Month : August | Volume : 5 | Issue : 4 | Page : 906 - 911

Rapid Maxillary Expansion: A Unique Treatment Modality in Dentistry

S. Arvind Kumar, Deepa Gurunathan, Muruganandham, Shivangi Sharma

Department of Pedodontics and Preventive Dentistry, Saveetha Dental College and Hospitals. PG Student, Department of Orthodontics, Saveetha Dental College and Hospitals. Shivangi Sharma, B.D.S.

Correspondence Address :
Dr. S. Aravind Kumar
Department of Orthodontics
Saveetha Dental College
Chennai 600077.
Mobile: 9841299939
Phone: 04426801581-85


Background: Rapid Maxillary expansion or palatal expansion as it is sometimes called, occupies unique niche in dentofacial therapy. Rapid Maxillary expansion is a skeletal type of expansion that involves the separation of the mid-palatal suture and movement of the maxillary shelves away from each other.

Materials and Methods: An objective approach to the design of a suitable appliance should be made by preparing a list of criteria based on the biomechanical requirements of RME.

Results: RME effects the maxillary complex, palatal vaults, maxillary anterior and posterior teeth, adjacent periodontal structures to bring about an expansion in the maxillary arch.

Conclusion: The majority of dental transverse measurements changed significantly as a result of RME.


Rapid maxillary expansion, Nasal obstruction, Maxillofacial complex

Rapid maxillary expansion (RME) is a dramatic procedure with a long history. Rapid Maxillary expansion or palatal expansion as it is sometimes called, occupies unique niche in dentofacial therapy. Rapid Maxillary expansion or Split palate is a skeletal type of expansion that involves the separation of the mid-palatal suture and movement of the maxillary shelves away from each other.

Anatomy The tenacity of circummaxillary attachments due to buttressing is strong postero-supero-medially and postero supero laterally. A palatine bone forms an intimate relationship with maxilla to form complete hard palate (or) floor of nose and greater part of lateral wall of nasal cavity.

It articulates anteriorly with maxilla through transverse palatal sutures and posteriorly through pterygoid process of the sphenoid bone. The interpalatine suture joins the two palatine bones at their horizontal plates and continous as inter maxillary sutures. These sutures forms the junction of three opposing pairs of bones: the premaxillae, maxilla, and the palatine. The entire forms mid-palatal suture, (Table/Fig 1), (Table/Fig 2).

SUTURES Mid Palatine Suture plays a key role in R.M.E (1). i. Infancy - Y-shape (Table/Fig 3) ii. Juvenile - T-shape iii. Adolescence - Jigsaw puzzle (Table/Fig 4) As sutural patency is vital to R.M.E, it is important to know when does the suture closes by synostosis (2) and on an average 5% of suture in closed by age 25 yrs.Earliest closure occurs in girls aged 15 yrs. Greater degree of obliteration occurs posteriorly than anteriorly.

Ossification comes very late anterior to incisive foramen – this is important when planning surgical freeing in late instances of RME (3).

Factors to be considered prior to expansion

Important factors to be considered in Rapid Maxillary Expansion:

1. Rate of Expansion: By expanding at the rates of 0.3-0.5mm per day, active expansion is completed in 2-4 weeks, leaving little time for the cellular response of osteoclasts and osteoblasts seen in slow expansion.

2. Form of Appliance:
As the thrust is delivered to the teeth at the inferior free borders of the maxilla, expansion mustreach to the basal portions. The form of appliance will play an important role in this effort, according to its rigidity or flexibility, i.e. anchorage or control of tipping.

3. Age and Sex of the patient:

The increasing rigidity of the facial skeleton with advancing age restricts bony movements remote from the appliance of expansion, which differs in both sexes.
4. Discrepancy between maxillary and mandibular first molars & bicuspid width is 4mm or more RME indicated. 5. Severity of cross bite i.e number of teeth involved. 6. Initial angulation of molars or premolars: When the maxillary molars are buccally inclined, conventional expansion will tip them further into the buccal musculature; and if themandibular molars are lingually inclined, the buccal movement to upright them will increase the need to widen the upper arch. 7. Assessment of roots of deciduous tooth 8. Physical availability of space for expansion. 9. Nasal Obstruction: All patients considered for RME should be examined for nasal obstruction and, if obstruction is found, they should be referred to an otolaryngologist before orthodontic treatment. 10. Medical history: Since the efficacy of maxillary expansion depends on suture patency and the flexibility of craniofacial compelex to adapt to mechanical changes hence medical conditions altering these should be considered. 11. Meatbolic disorders: Many metabolic disorders are found associated with suture synotoses which include hyperthyroidism, hypophosphatemic vitamin D-resistant rickets, and mucopolysaccharidoses and mucolipidoses. These disorders are mostly associated with bone metabolism. Maxillary expansion would be futile even in young patients if they are suffering from any of these diseases. 12. Periodontal Type: It is essential to record the thickness of the gingival tissues during clinical evaluation of the periodontium. This is especially important because a thin and delicate gingiva might be prone to recession after traumatic, surgical, or inflammatory injuries (4). 13. Mucogingival Health: Orthodontic tooth movement has significant effect on the mucogingival tissues and hence it is important to asses the periodontal health of the patient before performing OME.

Patients who have lateral discrepancies that result in either unilateral or bilateral posterior crossbites involving several teeth are candidates for RME.

Anteroposterior discrepancies are cited as reasons to consider RME. For example, patients with skeletal Class II, Division 1 malocclusions with or without a posterior crossbite, patients with Class III malocclusions, and patients with borderline skeletal and pseudo Class III problems are candidates if they have maxillary constriction or posterior crossbite.

(Table/Fig 5) shows the various factors responsible for constricted maxillary arches.

CONTRAINDICATIONS OF RME Patients who have anterior open bites, steep mandibular planes, and convex profiles are generally not well suited to RME.

Patients who have skeletal asymmetry of the maxilla or mandible, and adults with severe anteroposterior and vertical skeletal discrepancy.

HAZARDS OF RME • Oral hygiene • Length of fixation • Dislodgement and breakage • Tissue damage • Infection • Failure of suture to open

Rapid maxillary expansion can be of two types1. Tissue borne: Haas type expansion. 2. Tooth borne : Banded – Hyrax or Biedermann type. Bonded maxillary expansion. Minne Expander or Isaacson type.

Diagnostic Aids Case History, Clinical examination, study models, radiographs - maxillary occlusal, P.A. cephalogram. 1. A radiologically visible midpalatal suture corresponds histologically to a predominantly straight running oronasal suture, which projects largely into the saggital X-ray path 2. Radiological invisible suture corresponds histologically to a relatively large area of interdigitation, an oblique running suture course in relation to X-ray path or bone structures projecting above the suture course. Percentage of suture obliteration to be expected is also low in this group. 3. A radiologically invisible suture is not histologically equivalent of fused suture.

An objective approach to the design of a suitable appliance should be made by preparing a list of criteria based on the biomechanical requirements of RME.

1. Rigidity ( Resistance to Rotation):
An RME is most likely to be “applied to the permanent dentition when there is considerable resistance to maxillary separation, the resistance is found mainly in those very areas where expansion is required, i.e., in the basal portion of the maxillae; yet the force is applied remotely, to teeth at the free lower border.
2. Tooth Utilization: (No. of teeth included in appliance) (a) Load distribution: As the entire lower portions of the maxilla are to be moved laterally, it would be best to incorporate as many teeth as possible & thus spread the load over the entire alveolar length instead of applying it only at a few isolated points
3. Expansion: (Dilating unit & action): The dilating mechanism can be a spring (or) a screw but a spring reduces the rigidity & control. A screw is far better but should have a thread of sufficient length to complete the expansion without interruption. 4. Economy:
(a). Time : The use of capsplints keep the clinical time to a minimum with good laboratory backup. Chairside work is limited to taking of impressions & bite registration.b. Material: The appliance which makes the least intrusion into the oral space will be best tolerated by patient. Here the banded appliances have a distinct advantage over the bulky capsplints
5. Hygiene: The form which produces the minimal covering of the dental and palatal mucosal tissues consists of bands and least amount of interconnecting material. But this design as the inherent disadvantage of too much flexibility. Cap splints should be fixation of choice, especially where rigidity is important & bands have their place, where there are difficulties in retention. In order to simplify instructions patients have been classified into 3 age groups [ 6]. 1. U pto age 15 years • 180° daily rotation can be met with turn of 90° both morning & evening. • Patient recalled after one week. 2. Age 15 to 20years • Increasing resistance for maxillary separation may cause a force buildup & pain to patients in this age group with turns of 90°. • Patients are asked to return after one week 3. Over age 25 years • The mid palatal suture often is opened surgically which relives much of the tension. Here it may not be necessary to reduce the overall rate of expansion in these patients. • Revisit within 3 -4 days • Pain to be reviewed during active RME, before continuing with patient management during subsequent visits. 4. P ain during RME: Completion of the desired expansion in the short time allotted requires strong forces which often produce painful effects.The clinician monitoring treatment by rate of expansion has only the modality of pain as a monitor and indication of excessive force buildup that may lead to possible tissue damage. 5. Instructions: (Subsequent) • First ask the patient & person turning the screw if there were any difficulties. This information may be volunteered as any persistent pain certainly will be. • Then check the central incisors for diastema. • Then examine the screw to see how much thread is exposed, which indicates regularity in turning. • The patients who complaints of pain when the screw is turned should be asked how long it lasts; it generally disappears if the suture is open. Advice that 2nd 45° turn of screw not be made before the pain generated by the first has dissipated. • With patients overage 20 years it is difficult to differentiate b/w the pain from on unopened suture & that from skeletal rigidity. In event of non opening of suture, surgical freeing should be considered. • Should difficulties (or) minor illnesses arise during the active expansion phase, it may be stopped & resumed later. 6. How much to expand: Expansion should stop when the maxillary palatal cusps are level with the buccal cusps of the mandibular teeth (6)(7). Young growing patients – two turns each day for the first 4 to 5 days, one turn each day for the remainder of RME treatment; In adult (non-growing) patients – because of increased skeletal resistance, two turns each day for the first 2 days, one turn each day for the next 5 to 7days, and one turn every other day for the remainder of RME treatment.
7. Integration:• Malocclusion often has a different appearance & its easier to treat after RME as result of changed maxillomandibular relationship. • Extractions also should be left until after RME, not that much relief will gained from crowding & will eliminate extractions only in mild cases but expansion may help in better clarification of this issue. • A palate covering retainer is satisfactory but may be some what awkward in combination with a fixed appliance to align the teeth as 1st stage of treatment proceeds. • When functional appliances are to be used, the clinician must be sure that it has been fully accepted before discarding the retention plate. • With fixed appliances, the palatal arch must be used.

Rapid maxillary expansion occurs when the force applied to the teeth and the maxillary alveolar processes exceed the limits needed for orthodontic tooth movement.. The appliance compresses the periodontal ligament, bends the alveolar processes, tips the anchor teeth, and gradually opens the mid-palatal suture (Table/Fig 6).

It is seen that the two halves of the maxilla rotated in both the sagittal and frontal planes. The maxilla was found to be more frequentlydisplaced downward and forward (8). Haas suggested when the midpalatal suture opens, the maxilla always moves forward and downward. Skeletal changes in vertical and anterior displacement of maxilla with bonded rapid palatal expansion appliances using the lateral cephalograms showed that downward and anterior displacement of the maxilla may be minimized or negated with the use of the bonded appliance.

The palatine processes of the maxilla were lowered as a result of the outward tilting of the maxillary halves, also the palatal vault height decreased significantly during RME. Palatal height returned to pretreatment values one year after expansion and increased an average of 0.5mm two years after treatment.

It has been seenin studies that sincebone is resilient, lateral bending of the alveolar processes occurs early during RME (6).

The immediate effect of applying force to the suture results in trauma. Small, localized tears occurred within the suture from the localized blood vessels. These small defects were filled with exudate, a few extravasated red blood cells, scattered filaments of fibrin, and a few fine collagen fibrils (9). A transient polymorph response was noted in the region of the defects in the first 12 hours and thereafter was not seen again. Following the polymorph response, an influx of macrophages and pioneer fibroblasts into the defect occurred by 24 hours.

Within 3 to 4 days, bone formation had begun at the margins of the suture achieved by the pre-existing and undamaged osteoblasts. These formed successive lamellae along the suture margin. The collagen fibers and cells were aligned transversely across the suture corresponding to levels of tension. New bone formation now occurred along the same axis as trabeculae formed at right angles to the lamellae deposited initially at the suture margins.

With diminution and cessation of the expansion force (2 to 3 weeks), remodeling of both the bone and the suture occurred by the osteocytic and fibrocytic cell series until normal sutural dimensions were achieved..

The mineral content within the suture rose rapidly during the first month after the completion of suture opening. The mineral content in the bone beside the suture decreased rapidly in the first month but returned to its initial level within 3 months (10) .

From the patient’s point of view, one of the most spectacular changes accompanying RME is the opening of a diastema between the maxillary central incisors. It is estimated that during active suture opening, the incisors separate approximately half the distance the expansion screw has been opened. Following this separation, the incisor crowns converge and establish proximal contact. If a diastema is present before treatment, the original space is either maintained or slightly reduced. The mesial tipping of the crowns is due to the elastic recoil of the transseptal fibers. Once the crowns contact, the continued pull of the fibers causes the roots to converge toward their original axial inclinations. This [Table/Fig-6]: Effects of RME on mid palatine suture cycle generally takes about 4 months (Table/Fig 7),(Table/Fig 8), (Table/Fig 9), .

With the initial alveolar bending and compression of the periodontal ligament, there is a definite change in the long axis of the posterior teeth. Teeth show buccal tipping and believed to extrude to a limited extent (11) (Table/Fig 10).

The greatest increase in uprighting of the buccal segments was in the bonded RME case for the lower arch. RME could lead to a concurrent expansion of the lower arch as much as 4 mm in inter-canine width and 6 mm in inter-molar width (12) [Table/Fig-11] (figure to be inserted after this line i.e 11)].

All craniofacial bones directly articulating with the maxilla were displaced except the sphenoid bone.The cranial base angle remained constant. Displacement of the maxillary halves was asymmetric, and the sphenoid bone, not the zygomatic arch, was the main buttress against maxillary expansion.

Effects of RME on nasal volume changes
The use of maxillary expansion has been extended to nasal obstruction , as it has been suggested that nasal width and volume increases by RME (13). A 5.1 percent increase in nasal volume has been reported in patients after RME according to a study by Deeb W in Pubmed.

Effect of RME on soft tisue
According to a study by, the effect of RME on soft tissues, the nose tip and soft tissue Point A followed the anterior movement of the maxilla and maxillary incisors. Nihat Kilic and et al , concluded in their study that the soft tissue facial angle decreases and the H angle and profile convexity increases after RME. Also the H angle and profile convexity were statistically significant for their study (14).

Adva ncements in treatment
The most recent method used in the treatment of maxillary transverse deficiency (MTD) is Surgically Assisted Rapid Palatal Expansion (SARPE). Orthopedic Maxillary expansion (OME), in mature patient has been found associated with laterally tipping of teeth , extrusion , periodontal membrane compression, buccal root resorption, alveolar bone bending, fenestration of buccal cortex, palatal tissue necrosis, pain and instability of expansion. Because of the complications of OME SARPE has been recommended as a treatment of choice.

Recent advances in molecular biology has identified the underlying mechanism in suture fusion which is an important criteria for successful long term maxillary expansion. Increased rate of cell numbers and cell differentiation can cause the formation of a bony obliteration in between the sutures.

Role of Lithium
Effect of Lithium has also been studied related to RME by Tang H and et al,they found out that lithium treatment could aid to improve stability of ortho treatment like RME because beta catenin formation enhances new bone formation.

Expansion through maxillary suture widening by rapid maxillary expanders has been claimed to promote stability after retention. Stability has been attributed to the skeletal component of arch enlargement obtained by the expansion appliance as opposed to dental expansion as a result of edgewise appliance mechanotherapy.The causes of Relapse are: • High stress accumulated between the articulations of the craniofacial complex. • Tension produced in the palatal mucosa. • Imbalance between the buccal and lingual pressures, which is created as a result of maxillary expansion. • The application of a fixed retainer immediately and subsequent to rapid maxillary expansion, then followed by an intermittent removable retention appliance is highly recommended.


The majority of dental transverse measurements changed significantly as a result of RME. The maturity of the maxilla-facial structures determine the time and success rate of the treatment with RME.


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