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ti c R ev ie w International Orthodontics 2022; 20: 100657 Websites: www.em-consulte.com www.sciencedirect.com Available online: 23 June 2022 Keywords Pharyngeal airway Nasal cavity Rapid palatal expansion Rapid maxillary expansion MARPE tome 20 > n83 > September 2022 https://doi.org/10.1016/j.ortho.2022.100657 © 2022 The Authors. Published by Elsevier Masso Sy st em a Interest of miniscrew-assisted rapid palatal expansion on the upper airway in growing patients: A systematic review Simon Prévé, Beatriz García Alcázar Centro odontológico de inovación y especialidades avanzadas, Dental School, University Alfonso X El Sabio, Madrid, Spain Correspondence: Simon Prévé, Calle de Albarracín, 35, 28037 Madrid, Spain. sprev@myuax.com Summary Objective > This systematic review aimed to identify, evaluate, and provide an overview of the available literature regarding the use of miniscrews in the rapid maxillary expansion (RME) on the upper airway. Methods > The eligibility criteria were prospective trials that compared RME and miniscrew- assisted rapid maxillary expansion (MARPE) regarding airways. A search of studies in Medline (via PubMed), the Cochrane Library, Scopus and Scielo that measured the effects on the upper airway was conducted until May 8, 2022. Two reviewers independently selected the studies, extracted the data, and assessed the risk of bias for systematic reviews thanks to the Cochrane Risk of Bias tool. Reporting of this review was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results > Out of 160 potentially eligible studies, 7 were considered for systematic review. The measurement of MARPE on airway was done with CBCT, rhinometry, and acoustic rhinomanometry. In total, 344 patients were assessed. Two included studies showed high risk of bias and the rest showed low to moderate risks of bias. Tooth-bone-borne RME significantly improved nasal airflow [(Mean difference (MD) 52.7 cm3/s, 95% confidence interval (95% CI) (9.0–96.4), P = 0.020)], reduced nasal resistance (MD 0.20 Pa/cm3, 95% (0.38–0.02), P = 0.028), Skeletal expansion at the level of the nasal cavity was significantly greater in the MARPE group. The magnitude of the expansion at the posterior level of the nasal cavity was almost two times higher in the tooth-bone- borne group [(MD) 1.75 mm, 95% (1.16–2.35) and (MD) 0.78 mm, 95% (0.11–1.45), P < 0.001] Conclusions > The short-term airflow changes after MARPE seems promising. Additionally, MARPE is associated with greater skeletal maxillary expansion after retention, at various levels of the nasal cavity, compared to conventional RME. Introduction Transverse maxillary deficiency is a frequently observed condi- tion in the orthodontic patient, and is commonly presented in the form of unilateral or bilateral posterior crossbite [1]. The n SAS on behalf of CEO. This is an open access artic aetiology of posterior crossbite is multifactorial. Among others, poor oral habits such as low tongue position, atypical swallow- ing and altered breathing patterns due to adenoids and large tonsils may contribute to the establishment of maxillary le under the CC BY license (http://creativecommons.org/licenses/by/4.0/). http://crossmark.crossref.org/dialog/?doi=10.1016/j.ortho.2022.100657&domain=pdf mailto:sprev@myuax.com https://doi.org/10.1016/j.ortho.2022.100657 http://creativecommons.org/licenses/by/4.0/ S. Prévé, B. García Alcázar Sy st em at ic R ev ie w constriction, altered nasal breathing also have been associated with maxillary transversal deficiency [2]. When a skeletal con- stricted maxillary arch is diagnosed in adolescents, the rapid maxillary expansion (RME) based on an orthopaedic action which separates the two hemi-maxillaries at the level of the median palatal suture is the treatment of choice [3]. It was Angell [4] in 1860 who first described rapid maxillary expansion, which was soon discredited, nevertheless since the 1960s it has been one of the most widely used therapeutic instruments. It is conventionally performed in the growing child by means of a palatal expander which rests on the teeth (2 or 4 bands) and has an expansion screw which is usually activated twice a day, i.e., 0.5 mm per day [5], although obtaining an expansion of the maxillary arch being mostly dental and less skeletal [6,7]. The advent of mini-screws over the last twenty years has offered patients new treatment alternatives when conventional approaches are limited. The idea of using a skeletal anchor for RME is to be able to achieve greater skeletal expansion of the maxilla through a greater opening of the mid-palatal suture [8,9], thus since its arrival in our practice, questions have arisen about the use of mini-screw assisted palatal expansion versus conventional expansion devices. However, to date, there is only one meta-analysis comparing their effects on the dimensions and functions of the airway, but the latter included only 3 studies making it worthwhile to complete [10]. The aim of our literature review is therefore to assess the value of mini-screw assisted rapid palatal expansion on the upper airway in comparison with conventional tooth/tissue anchored devices in all studies published up until May 2022 in order to find new indications for use in our practice. Materials and methods Protocol and registration The present study was conducted and reported according to the preferred reporting items for systematic reviews and meta- analyses (PRISMA) guidelines [11] which were used to develop a protocol that was submitted to PROSPERO database (ID: 331280). All versions of the protocol are available at https://www.crd. york.ac.uk/prospero. Eligibility criteria This systematic review was conducted to answer the question of whether changes in expander design influence the outcome on the upper airway. Only randomized controlled trials that com- pared the effects of the MARPE with conventional RME on airway in growing subjects were included. Studies that combined the MARPE protocols with another treat- ment (e.g., maxillary traction with a face mask), or that applied the MARPE protocols using surgical procedures to assist in open- ing the palatal suture were not included. In addition, studies that evaluated patients with craniofacial development pathologies, 2 clefts, and syndromes were excluded. Review articles, case reports, case series, and expert opinions were not included in this systematic review. According to the Participants-Interventions-Comparisons-Out- come-Study design (PICOS) strategy, randomized controlled clinical trials on human patients were included if they met the following selection criteria: � Participants (P): patients of both sexes, without restriction of age, socio-economic classification or ethnicity, who have been diagnosed with maxillary transverse deficiency or posterior crossbite. � Intervention (I): MARPE. � Comparison (C): conventional RME protocols anchored to the teeth and/or mucosa without the use of mini-implants. � Outcomes (O): changes in nasal cavity width, nasopharyngeal volume or nasal flow and resistance. � Study types (S): Randomized clinical trials. Information sources, search strategy and selection of studies To find articles on the effects of maxillary bone-anchored and hybrid expansion on the upper airway, the following four elec- tronic databases were systematically searched: MEDLINE (via PubMed), the Cochrane Library, Scopus, and Scielo. To gather eligible studies, a search strategy was developed for PubMed and other databases, matching MeSH terms according to the following equation: ("Palatal Expansion Technique'' [MAJR] OR "maxillary expansion'' OR ((expand* OR expands* OR distract*) AND (maxill* OR palat*))) AND (("bone-anchorage'' OR "bone-anchored'' OR "bone-borne'' OR "tooth-anchored'' OR "tooth-borne'' OR "mini-implant'' OR "miniscrew'' OR "mini- screw'' OR "mini-implant'' OR "skeletal anchorage'' OR "skele- tally-anchored'' OR "hybrid'' OR "hybrid Hyrax'' OR "hybrid-Hyrax'' OR "marpe'')) AND ("airway'' OR "airflow'' OR "nasal width'' OR "nasal cavity''). An initial screening of titles and abstracts was performed by two separate readers (SP and BGA), to reduce the risk of individual error, who independently selected all studies that met the eligibility criteria. The same protocol was applied for the extrac- tion of study characteristics (study design, setting, country, patient number, sex, age, appliances, treatment duration, tim- ing of follow-up, activation protocol, measurement method, and outcome measured). In the case of abstracts that did not provide sufficient information, the full texts were retrieved for analysis. The final selection was made by reading the studies thoroughly, again by both readers. In case of disagreement, each article was reread and discussed with a third reviewer (INS) until consensus was reached. The search was conducted until May 2022 and included articles between 2001 and 2022. Apart from the filter of human trials, no other filters for language, year of publication, and status were applied. tome 20 > n83 > September 2022 International Orthodontics 2022; 20: 100657 ys te m at ic R ev ie w Assessment of the risk of bias in the included studies The reviewers independently assessed the included studies' risk of bias using the tool described in the Cochrane Handbook for Systematic Reviews of Interventions [12]. The risk of bias was assessed in the following six areas for each study included: S � F P to generation of random sequences (selection bias); � allocation concealment (selection bias); � blind evaluation of results (detection bias); � incomplete data on outcomes (attrition bias); � selective reporting (reporting bias); � other biases. The overall risk of bias was ranked in the following order: igure 1 RISMA flow diagram depicting the selection of the eligible studies me 20 > n83 > September 2022 3 � low risk of bias (plausible bias that is unlikely to seriously affect the results) if all key areas have been assessed as having a low risk of bias; � unclear risk of bias (plausible bias that raises some doubt about the results) if one or more key areas were assessed as having an unclear risk of bias; � high risk of bias (plausible bias that seriously undermines confidence in the results) if one or more key areas have been assessed as having a high risk of bias. Results Study selection The flowchart of the research selection procedure, in accordance with the PRISMA guideline, is presented in figure 1. S. Prévé, B. García Alcázar Sy st em at ic R ev ie w The electronic database search identified a total of 160 articles. After eliminating 85 duplicates, a total of 75 studies were screened by title and abstract to identify potentially eligible articles. The selection led to the exclusion of 67 publications, and the full texts of the remaining 8 articles were retrieved and analysed according to the eligibility criteria. Subsequently, 1 arti- cle was excluded after full text assessment because it was a retrospective cohort study [13]. Finally, seven randomized con- trolled trials were considered eligible for this systematic review [14–20]. Study characteristics All the selected studies (table I) were identified as randomized controlled trials, all evaluated growing patients; three evaluated prepubertal (adolescent) patients [15,17,18], and the other four evaluated patients in the final stages of growth (late adoles- cents) with a total of 344 subjects [14,16,19,20]. Regarding the design of conventional appliances; four studies used expanders with four bands on the first premolars and first molars [14,16,19,20], and three studies used expanders with only two bands on the first upper molars [15,17,18]. The design of the mini-screw devices varied from study to study. Although TABLE I Summary of the qualitative analysis of the included studies in relat expander. Study Sample Observ Kabalan et al. [14], 2015, RCT (n = 61) Hyrax: n = 20, 14.1Y, 5M/15F MARPE: n = 20, 14.2Y; 8/13F Control: n = 21, 12.9Y, 6M/15F T1 = pr T2 = Bazargani et al. [15], 2018, RCT (n = 40) Hyrax: n = 19, 9.7Y, 11M/8F MARPE: n = 21, 10.2Y, 10M/11F T0 = pr T1 = po Cheung et al. [16], 2020, RCT (n = 51) Hyrax: n = 19, 13.8Y, 10M/9F MARPE: n = 19, 14.3Y, 8M/11F Keyless: n = 13, 14.6Y, 2M/11F T0 = pr T1 = Bazargani et al. [17], 2021, RCT (n = 52) Hyrax: n = 26, 9.3Y, 13M/13F MARPE: n = 26, 9.5Y, 13M/13F T0 = pr T1 = po T2 Garib et al. [18], 2021, RCT (n = 34) Hyrax: n = 14, 11.4Y, 8M/6F MARPE: n = 18, 10.8Y, 10M/8F T1 = pr T2 = Mehta et al. [19], 2022, RCT (n = 60) Hyrax: n = 21, 13.9Y MARPE: n = 20, 13.69Y Control: n = 19, 13.3Y T1 = pr T2 = T3 = 2Y a Gokce et al. [20], 2022, RCT (n = 46) Hyrax: n = 15, 12.8Y, 9M/6F Haas: n = 15, 12.5Y, 3M/12F MARPE: n = 16, 13.1Y, 3M/13F T0 = pr T1 = po T2 = AR: acoustic rhinometry; C: control; CBCT: cone-beam computerized tomography; F: fema 4 with some differences (design and number of mini-implants used for anchorage), three studies achieved an exclusively bone-supported expander [14,19,20], while the other four used a hybrid dental and bone anchored expander [15–18]. One study investigated the influence of the expander design on the airway function pre- and post-expansion with no follow up [15]. The other studies compared the changes in the airway dimension with measurements made post-expansion [17,20], after 3 months for one study [20], after a 6 months period [14,16,19], a year for 2 other studies [17,18] and Mehta's trial even carried a follow up of 2 years and 8 months [19]. The tools used for airway assessment differed among the stud- ies and included CBCT for linear measurements of the nasal cavity width changes in five studies [16–19], acoustic rhinometry was used in two others to evaluate the volume changes in the nasal cavity [14,20], finally Bazargani et al. [15] assessed the nasal airflow and resistance thanks to active anterior rhinometry. Risk of bias in studies The risk of bias assessment is shown in figure 2. The Cochrane risk of bias tool classified two studies as having a low risk of bias, ion to study design, sample size, gender, age and type of palatal ation period Tool Type of device e-treatment 6 months AR CBCT 4 bands Hyrax expander vs. 2 miniscrew bone-borne expander vs. control e-treatment st-expansion Rhinomanometry 2 bands Hyrax expander vs. 2 bands and 2 miniscrews hybrid Hyrax expander e-treatment 6 months CBCT 4 bands Hyrax expander vs. 2 bands and 2 miniscrews hybrid Hyrax expander vs. keyless expander e-treatment st-expansion = 1 year CBCT 2 bands Hyrax expander vs. 2 bands and 2 miniscrews hybrid Hyrax expander e-treatment 11 months CBCT 2 bands Hyrax expander vs. 2 bands and 2 miniscrews hybrid Hyrax expander e-treatment 6 months nd 8 months CBCT 4 bands Hyrax expander vs. 2 miniscrews bone-borne expander vs. control e-treatment st-expansion 3 months AR 4 bands Hyrax expander vs. acrylic bonded Haas expander vs. 2 miniscrews bone-borne expander le; M: male; MARPE: mini-implant assisted maxillary expansion; Y: years. tome 20 > n83 > September 2022 Figure 2 Risk of bias assessment for included randomized studies using the Cochrane Collaboration tool International Orthodontics 2022; 20: 100657 Sy st em at ic R ev ie w three as having a moderate risk of bias, and two as having a severe risk of bias. The main factors contributing to the risk of bias were missing data and selectivity of outcomes, as well as lack of information about the blindness of the assessors and allocation concealment. Results of individual studies Regarding the strictly skeletally-anchored expander, Kabalan et al. [14] found that even though the anatomical dimensions and function of the airway parameters have been improved in both hyrax and MARPE groups, the correlation between them was not significant (P > 0.05). These results are in agreement with those of Cheung et al.'s study [16], in which no significant difference was found inthis respect when comparing the hybrid tome 20 > n83 > September 2022 5 Hyrax and the tooth-borne expander. However, the study con- cluded that the increase in total upper airway volume was greater in prepubertal patients with MARPE, and in patients who had the smallest volume at the beginning of the study. Gokce et al. [20] tried to measure the volume changes in the nasal cavity using acoustic rhinometry, secondary to tooth-borne RME and bone-anchored RME. In their study, there were signifi- cant increases in nasal volume in all groups after the treatment (95%CI, P < 0.05) whereas in inter-group comparisons the changes were found to be similar (95%CI, P > 0.05). However, Mehta et al. [19] found that in the long term, purely bone- supported RME resulted in a significantly greater increase in nasal width at the anterior and posterior parts of the nasal cavity respectively of 1.75 mm (95%CI: 1.16–2.35, P < 0.001) and TABLE II Characteristics of included studies with respect to follow-up and outcomes. Study Measurement Parameters Value Significance Kabalan et al. [14], (2015) Nasal cavity volume changes: _Bone Expander group between T1 and T2 _Tooth Expander group between T1 and T2 Right Vol1 T1T2 before/after Lt Vol1 (mm3) T1T2 before/ after (Mean, SD) Right Vol1 (mm3) T1T2 before/after Lt Vol1 T1T2 before/after (Mean, SD) Right: 0.03, 1.27/0.38, 1 mm3 Left: �0.24, 1.4/0.06, 1.4 mm3 Right: �0.15, 1.64/�0.19, 1.89 mm3 Left: 0.19, 1.69/0.07, 1.75 mm3 P > 0.05 Bazargani et al. [15], (2018) Nasal airflow and resistance: Mean difference between Hyrax and Hybrid groups Nasal airflow cm3/s Mean difference (95% CI) Nasal Resistance Pa s/cm3 Mean difference (95% CI) Complete cases: 51.0 (9.6 to 92.5) Multiple imputation: 52.7 (9.0 to 96.4) Complete cases: 0.21 (0.4 to 0.04) Multiple imputation: 0.20 (0.4 to 0.02) P = 0.018*, P = 0.020*, P = 0.016*, P = 0.028* Cheung et al. [16], (2020) Nasal cavity volume changes: _Hyrax group between T1 and T0 _Hybrid Hyrax group between T1 and T0 _Keles group between T1 and T0 Nasal cavity volume (mm3) T1–T0—mean (SD) Nasal cavity volume (mm3) T1–T0—mean (SD) Nasal cavity volume (mm3) T1–T0—mean (SD) 1066.1 (8793.0) 2688.7 (3377.0) 1276.4 (5554.6) P = 0.32 Bazargani et al. [17], (2021) Nasal cavity width changes: Mean difference between MARPE and Hyrax groups T2- T0 P1/N1width (mm) T2-T0 Mean difference (95% CI) P1/N2 width (mm) T2-T0 Mean difference (95% CI) P2/N1 width (mm) T2-T0 Mean difference (95% CI) P2/N2 width (mm) T2-T0 Mean difference (95% CI) 1.1 (0.1 to 2.1) 1.2 (0.4 to 2.0) 1.1 (0.1 to 2.0) 0.8 (�0.2 to 1.8) P = 0.025*, P = 0.0005*, P = 0.023* P = 0.13 Garib et al. [18], (2021) Nasal cavity width changes: Mean difference between hybrid and hyrax groups T2-T1 Nasal cavity width (mm) T2-T1 Mean difference (95% CI) 1.15 (0.4 to 1.99) P = 0.004* Mehta et al. [19], (2022) Nasal cavity width changes: _MARPE group between T3-T1 _Hyrax group between T3-T1 PNCW (mm) T3-T1 MARPE Mean difference (95% CI) ANCW (mm) T3-T1 MARPE Mean difference (95% CI) PNCW (mm) Hyrax T3-T1 Mean difference (95% CI) ANCW (mm) T3-T1 Hyrax Mean difference (95% CI) 1.75 (1.16, 2.35) 1.15 (0.63, 1.67) 0.78 (0.11, 1.45) 0.93 (0.08, 1.78) P < 0.001*, P = 0.017*, P < 0.001*, P = 0.001* Gokce et al. [20], (2022) Nasal cavity volume changes: _Hyrax group between T2 and T1 _Bone-borne group between T2 and T1 _TTB group between T2 and T1 Nasal cavity volume changes T2-T0 (mm3) Mean difference (95% CI) Hyrax: 1.86 (0.91–2.81) TTB: 1.16 (0.26–2.05) Bone-borne: 2.52 (1.32–3.71) P > 0.05 ANCW: anterior nasal cavity width; CI: confidence interval; Lt: left nasal orifices; N1: nasal width at the most inferior part of cavum nasi distance; N2: nasal width at the widest part of cavum nasi; P1: apex first premolar; P2: apex first molar palatal root; PNCW: posterior cavity width; Rt: right nasal orifices; SD: standard deviation; TB: tooth-tissue-borne; Vol: volume; Vol1: mean change in nasal cavity volume from front of the nose; Vol2: mean change in nasal cavity volume to the minimum cross-sectional areas. Before and after refer to use of nasal decongestant. *Statistically significant (P < .05). S. Prévé, B. García Alcázar tome 20 > n83 > September 2022 6 Sy st em at ic R ev ie w International Orthodontics 2022; 20: 100657 Sy st em at ic R ev ie w 1.15 mm (95%CI: 0.63–1.67, P = 0.017) compared to the tradi- tional RME and control groups in a 2 years and 8 months follow up period. On the other hand, four studies compared the conventional hyrax expander with a hybrid teeth-bone-borne appliance, with regard to the increase in the width of the nasal cavity, two studies found significant results (P < 0.05) demonstrating the superiority of the hybrid expander over the Hyrax model in increasing the width of the nasal cavity [17,18]. Moreover Cheung et al. [16] found that the changes in the nasal cavity volume were more than twice greater in the tooth-bone borne group but this result was not significant (P = 0.32). Furthermore, Bazargani et al. [15], found that MARPE induced significantly higher nasal air flow values ((MD 52.7 cm3/s, (95%CI: 9.0– 96.4), P = 0.020)) than Hyrax and significantly lower nasal resistance values (MD 0.20 Pa s/cm3, 95%CI: 0.38–0.02, P = 0.028) in favour of the MARPE group. A brief description of the included and evaluated studies is presented in tables I and II. Discussion Summary of evidence This systematic review summarizes and critically appraises the evidence from randomized clinical trials that featured 344 patients on the potential upper airway benefits of MARPE over conventional RME. Although hybrid and strictly bone- anchored expanders were first described more than a decade ago [21,22], research comparing the two conceptions has been remarkably limited, and the results have often not coincided. It is known that the width of the nasal cavity and its volume increases after expansion through the intermaxillary suture, however, the clinical implication is not clearly quantified [23– 30]. Three of the included studies converged on the fact that conventional RME and MARPE resulted in significant expansion of the nasal cavity, albeit more so with bone anchorage [17–19]. Bazargani et al. [17] compared the dentoalveolar and skeletal effects of dental and hybrid expanders in patients aged 9.3 to 9.5 years with a one-year follow-up. He concluded that skeletal expansion at the mid-palatal suture was significantly greater in the hybrid group, but may not be clinically significant. The author also stated that the Hyrax expander worked well in young preadolescents, but that the hybrid expander may be more effective in cases of upper airway obstruction. These data are consistent with the results of Garibs et al.'s [18] trial which reported a two-fold increase in nasal cavity width in the MARPE group (2.26 mm) compared to the hyrax group (1.11 mm) even though this result contrasts with Toklu et al. [31] study which findings showed higher values for the conventional RME with an increased width of the nasal cavity ranging from 1.2 to 2.73 mm. Regarding volume changes of the nasal cavity, even though their results are not statistically significant both Cheung et al. [16] and Gokce et al. [22] found the MARPE designs to be tome 20 > n83 > September 2022 7 superior than the traditional hyrax, as shown in previous retro- spective studies [13,32]. Although it has been shown that RME in general can increase upper airway volume [33] the effect of this increase on improved breathing or quality of life is unclear. It should be noted here that, based on the current evidence, no recommendation can be made for the use of any type of MARPE for the treatment of ventilatory disorders. Data from a clinical trial included in this review indicate that RME with a hybrid expander was associated with higher nasal airflow and lower nasal airway resistance compared to conventional RME [15]. It has been reported in the literature that theaverage total nasal resistance in normal subjects after decongestion is between 0.15 and 0.5 Pa s/cm3 [34]. Therefore, the reduction in nasal airway resistance of 0.21 Pa s/cm3 shown by Bazargani et al. [15] in favour of MARPE could be considered close to the decongestant effect of a nasal spray, which certainly looks promising, for example, in children with nasal airway obstruction. Comparing the RME with hybrid or traditional expanders and the control group, Mehta et al. [19] found that in the short term, both showed similar expansion, but at long-term follow-up of 2 years and 8 months, the bone-supported expander produced a significant increase in palatal width compared to the conven- tional RME and control groups. In this study, the mean age was over 13 years. It is known that RME is more effective in younger patients, as demonstrated in Cheung's study where he found a greater increase in total upper airway volume in prepubertal patients (cervical vertebral maturation stage 1–3) than in patients past peak growth, and MARPE produced a greater increase than the Hyrax appliance in this category of subjects, however, the study found no significant difference in the vol- ume changes of the three compartments of the upper airway between MARPE and conventional expansion [16] which is in agreement with Abu Arqub et al.'s [10] systematic review. Limitations The data from the studies were very heterogeneous, selecting articles that met the eligibility criteria was difficult, and signifi- cant differences were found in the age of the patients, follow-up duration, and design of the devices used. In addition, the lack of information on baseline dysmorphia or activation protocols makes interpretation and generalisability of the observed results subject to caution. Conclusions Within the limits of the current evidence from randomized trials, this qualitative systematic review indicated that MARPE is asso- ciated with greater maxillary skeletal expansion at the palatal suture and nasal cavity width after retention compared to conventional RME. S. Prévé, B. García Alcázar ic R ev ie w A significant increase in nasal airflow and a reduction in airway resistance appears to be associated with the hybrid expander immediately after expansion. Re [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] te m at Author contributions: Simon Prévé carried out the conception and design of the study, carried out the acquisition of data, the analysis and interpretation of data, and drafted the article. ferences McNamara JA. Maxillary transverse defi- ciency. 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